CCE-CBD-025

Examiner Only Information

Questions

Q1. How would you explain Sarah’s test results and their significance?

• Prompt: How do you communicate potential prediabetes, hypercholesterolaemia, and mild CKD in a patient-friendly way?
• Prompt: How would you address her concerns?

Q2. What further tests or assessments are needed to clarify the diagnosis?

• Prompt: How would you confirm diabetes and assess cardiovascular risk?
• Prompt: When would you repeat or escalate testing?

Q3. What are the key components of a management plan for Sarah?

• Prompt: What lifestyle changes should be recommended?
• Prompt: When would you consider pharmacological intervention?

Q4. How would you counsel Sarah on long-term monitoring and prevention of complications?

• Prompt: What follow-up tests and reviews are required?
• Prompt: What preventive strategies should she adopt?

Q5. When would you consider referral to a specialist?

• Prompt: When is endocrinology, nephrology, or cardiology referral warranted?
• Prompt: What red flags suggest a need for urgent specialist review?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you explain Sarah’s test results and their significance?

The competent candidate should:

• Use clear, non-alarmist language while explaining abnormal results.
• Fasting glucose (7.1 mmol/L):
  • Falls into the impaired fasting glucose (IFG) range.
  • Possible prediabetes or early type 2 diabetes, requiring confirmation with further testing.
• Total cholesterol (6.5 mmol/L), LDL (4.2 mmol/L):
  • Above the recommended range for cardiovascular health.
  • Combined with family history, this increases her cardiovascular risk.
• eGFR (58 mL/min/1.73m²):
  • Suggests mildly reduced kidney function (possible early chronic kidney disease – CKD stage 2).
  • Reversible causes (e.g., dehydration, medication effects) should be excluded.
• Address concerns empathetically:
  • “These results indicate some early changes that we can act on now to reduce long-term health risks.”
  • “I’d like to repeat some tests and discuss ways to improve your health through lifestyle changes.”

---

Q2: What further tests or assessments are needed to clarify the diagnosis?

The competent candidate should:

• Confirm diabetes:
  • Repeat fasting glucose or perform HbA1c test to assess longer-term glucose control.
  • Consider oral glucose tolerance test (OGTT) if results remain borderline.
• Assess cardiovascular risk:
  • Blood pressure monitoring (home BP or ambulatory if needed).
  • Full lipid profile, including triglycerides and HDL.
  • QRISK2 or Australian CV risk calculator to estimate 5-year cardiovascular disease (CVD) risk.
• Kidney function assessment:
  • Repeat eGFR and check for trends.
  • Urine albumin-to-creatinine ratio (ACR) for early kidney damage.
• Consider additional tests based on history:
  • Liver function tests (LFTs) if metabolic syndrome suspected.
  • TSH if symptoms suggest hypothyroidism.

---

Q3: What are the key components of a management plan for Sarah?

The competent candidate should:

• Lifestyle modifications (first-line approach):
  • Weight loss (5-10% of body weight) to reduce diabetes and CVD risk.
  • Regular physical activity (at least 150 minutes per week).
  • Mediterranean or DASH diet to lower cholesterol and blood sugar.
  • Reduce salt intake to improve kidney and heart health.
• Pharmacological intervention (if required):
  • Consider statins (e.g., atorvastatin 10-20 mg) if CVD risk >10%.
  • Metformin if diabetes is confirmed and lifestyle alone is insufficient.
  • ACE inhibitors (e.g., perindopril) if hypertension or proteinuria is present.
• Follow-up plan:
  • Recheck fasting glucose, HbA1c, and cholesterol in 3-6 months.
  • Annual kidney function monitoring if CKD is confirmed.

---

Q4: How would you counsel Sarah on long-term monitoring and prevention of complications?

The competent candidate should:

• Regular health checks:
  • Annual diabetes screening if in the prediabetes range.
  • Blood pressure and lipid profile check every 6-12 months.
  • Routine kidney function monitoring.
• Preventive health measures:
  • Continue breast and cervical screening.
  • Vaccinations (influenza, pneumococcal if indicated).
• Encourage adherence to lifestyle changes:
  • Set achievable goals (e.g., walking 30 minutes daily).
  • Monitor progress through a food and exercise journal.

---

Q5: When would you consider referral to a specialist?

The competent candidate should:

• Endocrinology referral if:
  • HbA1c >7% despite lifestyle measures.
  • Atypical diabetes presentation (e.g., weight loss, autoimmune features).
• Nephrology referral if:
  • eGFR declines <45 mL/min/1.73m² or significant proteinuria is detected.
• Cardiology referral if:
  • High CVD risk requiring complex medication management.
  • Hypertension difficult to control despite lifestyle and medication.

---

SUMMARY OF A COMPETENT ANSWER

• Explains abnormal test results clearly and non-alarmingly.
• Orders appropriate confirmatory tests (HbA1c, lipid profile, urine ACR).
• Emphasises lifestyle changes as first-line intervention.
• Monitors long-term risks and ensures appropriate follow-up.
• Refers to specialists if diabetes, kidney disease, or cardiovascular risk progresses.

---

PITFALLS

• Failing to explain results in a way the patient understands.
• Not confirming abnormal results with repeat testing.
• Overprescribing medication before trialling lifestyle changes.
• Missing the need for long-term follow-up and prevention strategies.

---

REFERENCES

• RACGP Diabetes Management Guidelines
• Heart Foundation Cardiovascular Risk Assessment
• Kidney Health Australia CKD Guidelines

---

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

1. Communication and Consultation Skills

1.1 Engages the patient in a discussion about abnormal results and next steps.

2. Clinical Information Gathering and Interpretation

2.1 Identifies need for further testing to confirm diabetes, kidney function, and cardiovascular risk.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates prediabetes from diabetes and CKD stage 2 from transient eGFR decline.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based interventions for diabetes prevention and lipid management.

5. Preventive and Population Health

5.2 Encourages lifestyle modification and long-term monitoring.

6. Professionalism

6.3 Delivers patient-centred, ethical care in discussing abnormal results.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures proper follow-up, documentation, and referrals if needed.

9. Managing Uncertainty

9.1 Determines when watchful waiting vs escalation is appropriate.

10. Identifying and Managing the Patient with Significant Illness

10.3 Recognises early-stage chronic disease and implements preventive measures.

Competency at Fellowship Level

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