EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess Oliver’s respiratory condition?

• Prompt: What key features help differentiate bronchiolitis from other respiratory illnesses?
• Prompt: What red flag symptoms should be assessed?

Q2. What are the most likely diagnoses, and how would you confirm the diagnosis?

• Prompt: How would you differentiate between viral bronchiolitis, bacterial pneumonia, and asthma?
• Prompt: What role do investigations play in diagnosing bronchiolitis?

Q3. Outline an appropriate management plan, including parental education.

• Prompt: What supportive care measures are recommended?
• Prompt: How would you explain why antibiotics are not required?

Q4. What advice would you provide Oliver’s parents regarding symptom monitoring and when to seek further medical attention?

• Prompt: What are the red flag signs that require urgent review?
• Prompt: How would you reassure parents while ensuring safety-netting?

Q5. Oliver returns in two days with worsening symptoms, including increased work of breathing. What would you do next?

• Prompt: How would you reassess and escalate care if needed?
• Prompt: When is hospital referral appropriate?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess Oliver’s respiratory condition?

A comprehensive history is essential to differentiate bronchiolitis from other respiratory conditions and assess severity.

1. Symptom Characteristics:

• Onset, duration, and progression: Has cough or wheeze worsened?
• Cough characteristics: Barking, productive, or dry.
• Feeding difficulties: Poor feeding suggests increased respiratory effort.
• Work of breathing: Any pauses in breathing, nasal flaring, or grunting.

2. Red Flag Symptoms:

• Episodes of cyanosis, lethargy, or apnoea.
• Severe respiratory distress: Use of accessory muscles, head bobbing.
• Decreased urine output (>12 hours without wet nappy).

3. Risk Factors for Severe Disease:

• Prematurity (<37 weeks), congenital heart disease, chronic lung disease.
• Passive smoking exposure.
• Immunocompromised status.

4. Previous Medical History:

• Prior episodes of wheezing or hospitalisations for respiratory illness.
• Family history of asthma, atopy, or allergic conditions.

5. Social and Daycare Exposure:

• Recent viral illnesses in household or daycare setting.

A structured history helps risk stratify, identify red flags, and guide management.

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Q2: What are the most likely diagnoses, and how would you confirm the diagnosis?

Oliver’s symptoms are suggestive of acute viral bronchiolitis.

1. Most Likely Diagnoses:

• Viral bronchiolitis: Most common in infants <2 years, presents with cough, wheezing, and low-grade fever.
• Viral-induced wheeze: If family history of asthma or recurrent wheezing episodes.
• Bacterial pneumonia: If focal crackles, high fever, or significant tachypnoea.

2. Key Differentiating Factors:

• Bronchiolitis: Diffuse wheezing, crackles, age <2 years, typically RSV-related.
• Pneumonia: Localised crackles, high fever, respiratory distress.
• Asthma: Recurrent episodes, response to bronchodilators, atopic history.

3. Role of Investigations:

• Diagnosis is clinical – no routine tests required.
• Pulse oximetry: If SpO₂ <92%, consider escalation.
• CXR: Only if atypical features (severe respiratory distress or concern for pneumonia).

A clinical diagnosis based on history and examination ensures appropriate treatment.

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Q3: Outline an appropriate management plan, including parental education.

Oliver’s bronchiolitis is mild, requiring supportive care and parental reassurance.

1. Supportive Care (First-Line Management):

• Ensure hydration: Encourage small, frequent feeds.
• Nasal saline drops and gentle suctioning.
• Paracetamol for fever or discomfort.
• Avoid cough syrups or decongestants.

2. Avoid Unnecessary Medications:

• No role for antibiotics (viral illness).
• No benefit from bronchodilators unless trial suggests improvement.
• Corticosteroids are not effective in bronchiolitis.

3. Parent Education:

• Explain that bronchiolitis is self-limiting and usually improves in 7-10 days.
• Symptoms peak around days 3-5 before improving.

4. Follow-Up and Safety-Netting:

• Review if symptoms worsen (increased respiratory distress, poor feeding, lethargy).

Reassuring parents and providing clear guidance on home care and warning signs ensures safe management.

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Q4: What advice would you provide Oliver’s parents regarding symptom monitoring and when to seek further medical attention?

Parental education is critical in managing bronchiolitis at home.

1. Expected Symptom Course:

• Cough and wheezing may persist for up to 2 weeks.
• Day 3-5 is usually the worst phase.

2. Red Flag Symptoms Requiring Urgent Review:

• Increased breathing effort: Severe work of breathing, grunting, nasal flaring.
• Cyanosis or pale, lethargic appearance.
• Inability to feed or fewer wet nappies (<4 in 24 hours).
• Persistent fever >39°C despite paracetamol.

3. When to Seek GP Review:

• Symptoms not improving after 7-10 days.
• Concerns about feeding, hydration, or persistent wheezing.

Providing clear, structured safety-netting empowers parents and reduces unnecessary antibiotic use.

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Q5: Oliver returns in two days with worsening symptoms, including increased work of breathing. What would you do next?

Oliver’s worsening condition requires urgent reassessment to determine the need for hospitalisation.

1. Reassess Severity:

• Respiratory rate, oxygen saturation, work of breathing.
• Mental state (lethargy, irritability).
• Hydration status (wet nappies, oral intake).

2. Indications for Hospital Referral:

• SpO₂ <92% on room air.
• Severe respiratory distress (marked retractions, grunting, apnoea).
• Inability to feed or signs of dehydration.

3. Emergency Management Before Transfer:

• Administer oxygen if SpO₂ <92%.
• Trial nebulised hypertonic saline if available.
• Escalate care via ambulance for hospital admission.

4. Hospital-Based Management:

• Supportive care (oxygen, IV fluids if needed).
• Escalation to high-dependency care if respiratory failure develops.

Timely identification and referral prevent serious complications.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking, focusing on red flags and risk factors for severe bronchiolitis.
• Correct differentiation between bronchiolitis, pneumonia, and asthma to guide management.
• Supportive care approach, avoiding unnecessary antibiotics or steroids.
• Effective parental education, including symptom course, home care, and safety-netting.
• Timely escalation of care if worsening respiratory distress develops.

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PITFALLS

• Failure to assess hydration status, leading to missed dehydration.
• Unnecessary antibiotic prescription, as bronchiolitis is viral.
• Overuse of salbutamol or corticosteroids, which are ineffective in bronchiolitis.
• Lack of structured parental education, resulting in unnecessary hospital visits.
• Delayed referral for severe cases, increasing risk of respiratory failure.

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REFERENCES

• (RCH Melbourne) – Australian Bronchiolitis Guidelines
• National Institute for Health and Care Excellence (NICE) – Bronchiolitis
• RACGP – RACGP Guidence for Bronchiolitis
• GP Exams – Acute bronchitis/bronchiolitis

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD