CCE-CBD-066.1

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you explain the diagnosis of reactive arthritis to Helen?

• Prompt: How would you describe the condition in plain language?
• Prompt: What’s the link between the infection and joint symptoms?

Q2. What further investigations (if any) would you consider?

• Prompt: Are there any other causes or complications you need to exclude?
• Prompt: What ongoing monitoring would you suggest?

Q3. What would be your management plan for Helen’s reactive arthritis?

• Prompt: Outline both pharmacological and non-pharmacological management.
• Prompt: How would you manage the identified infection?

Q4. What is the expected prognosis for Helen, and what factors might influence this?

• Prompt: How would you discuss the prognosis and potential chronicity?
• Prompt: What complications should you warn Helen about?

Q5. When would you consider referring Helen to a rheumatologist?

• Prompt: What are the red flags for referral?
• Prompt: When might you consider starting disease-modifying anti-rheumatic drugs (DMARDs)?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you explain the diagnosis of reactive arthritis to Helen?

The competent candidate should:

• Use clear, jargon-free language to explain the diagnosis. “Helen, based on your history and tests, you have a condition called reactive arthritis. This happens when your immune system reacts to a previous infection—in your case, a gut infection and a recent chlamydia infection—and causes inflammation in your joints, eyes, and urinary system.”
• Explain the link between infection and symptoms. “Even though the infection has resolved, your body’s immune response is still ‘switched on’ and is mistakenly causing inflammation in areas like your knee, ankle, eyes, and urinary tract.”
• Provide reassurance and set realistic expectations. “For most people, this condition improves over weeks to months with treatment. A small number may experience ongoing joint symptoms.”
• Address Helen’s concerns about mobility and work. “We will work together to manage your symptoms and support you in maintaining your activities and work as much as possible.”

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Q2: What further investigations (if any) would you consider?

The competent candidate should:

• Consider additional investigations to rule out differentials and assess severity:
  • Joint aspiration already completed, excluding septic arthritis and crystals.
  • Renal function and liver function tests, before prescribing NSAIDs or DMARDs.
  • Repeat STI screen (including partner testing and treatment if necessary).
  • Uveitis screening: refer for ophthalmology review if visual symptoms arise.
• Plan ongoing monitoring:
  • Monitor inflammatory markers (CRP, ESR) to assess treatment response.
  • Urine dipstick to monitor for sterile pyuria or hematuria.
  • Document and track functional status.

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Q3: What would be your management plan for Helen’s reactive arthritis?

The competent candidate should:

• Initiate pharmacological treatment:
  • NSAIDs (e.g., naproxen 500 mg BD) as first-line.
  • Intra-articular corticosteroid injections if monoarthritis is severe.
  • Short course oral corticosteroids if multiple joints are involved and NSAIDs are insufficient.
• Address the underlying infection:
  • Treat chlamydia with doxycycline 100 mg BD for 7 days (or azithromycin 1g stat).
  • Ensure partner notification and treatment.
• Provide non-pharmacological management:
  • Physiotherapy referral for joint mobilisation and strengthening.
  • Advice on gradual return to activity, avoiding joint overuse.
  • Education on smoking cessation and healthy diet for immune health.
• Review in 2 weeks to assess response.

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Q4: What is the expected prognosis for Helen, and what factors might influence this?

The competent candidate should:

• Explain prognosis: “Most people recover within 3-6 months. Around 20% may have symptoms that last longer.”
• Discuss factors influencing prognosis:
  • Presence of HLA-B27 increases risk of chronicity.
  • Prompt treatment of infection reduces recurrence risk.
  • Poor response to NSAIDs or corticosteroids may warrant DMARDs.
• Warn about complications:
  • Chronic arthritis.
  • Recurrent uveitis.
  • Cardiac complications (rare).

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Q5: When would you consider referring Helen to a rheumatologist?

The competent candidate should:

• Refer to a rheumatologist if:
  • Symptoms persist beyond 6 months.
  • Multiple joints are involved and unresponsive to initial treatment.
  • DMARD initiation is considered (e.g., sulfasalazine, methotrexate).
  • Suspicion of progression to ankylosing spondylitis (persistent sacroiliitis, spinal involvement).
• Other specialist referrals:
  • Ophthalmology if vision affected.
  • Urology or sexual health if persistent urinary symptoms.

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SUMMARY OF A COMPETENT ANSWER

• Clearly explains reactive arthritis in lay terms.
• Orders appropriate investigations to confirm diagnosis and monitor.
• Implements comprehensive management, addressing infection and inflammation.
• Outlines prognosis and complications effectively.
• Recognises red flags for specialist referral.

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PITFALLS

• Failure to exclude septic arthritis in monoarthritis cases.
• Missing STI testing and partner notification.
• Over-reliance on NSAIDs without considering steroid or DMARD escalation.
• Neglecting to monitor vision symptoms suggestive of uveitis.
• Lack of follow-up planning and monitoring for chronic disease development.

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REFERENCES

• RACGP Guidelines
• Therapeutic Guidelines on Rheumatology
• Australian STI Management Guidelines
• Arthritis Australia Reactive Arthritis Factsheet

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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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Systematically collects and records relevant information.
2.2 Elicits and interprets findings from history and examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises a differential diagnosis.
3.2 Demonstrates rational and evidence-based decision making.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Selects and implements appropriate treatment, including pharmacological and non-pharmacological.

5. Preventive and Population Health

5.2 Implements prevention strategies appropriate to risk factors and lifestyle.

6. Professionalism

6.3 Shows commitment to patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.2 Follows guidelines and policies for patient management and referrals.

9. Managing Uncertainty

9.1 Recognises when to seek further information or refer.

10. Identifying and Managing the Patient with Significant Illness

10.2 Recognises patients who require complex management or specialist input.

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Competency at Fellowship Level

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