CCE-CBD-070

EXAMINER ONLY INFORMATION

QUESTIONS

Question 1:

What is your differential diagnosis, and how would you confirm the diagnosis?

• Prompts:
  • What are the distinguishing features of a boil/carbuncle compared to cellulitis or abscess?
  • When is imaging indicated?

Question 2:

Outline your management plan for John’s current condition.

• Prompts:
  • Would you perform an incision and drainage today?
  • What antibiotics are appropriate, considering his diabetes?

Question 3:

What preventive strategies would you recommend to John to reduce recurrence?

• Prompts:
  • Discuss diabetes management, skin hygiene, weight control, and smoking cessation.
  • Educate on early recognition and self-care of skin infections.

Question 4:

What factors increase John’s risk for complications, and how would you monitor him?

• Prompts:
  • Identify risk factors such as diabetes, obesity, and previous infections.
  • When would you refer him for hospital-based care?

Question 5:

How would you address John’s diabetes management in this consultation?

• Prompts:
  • What medication adjustments or education would you provide?
  • Would you refer him to a diabetes educator or allied health?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis, and how would you confirm the diagnosis?

The competent candidate should:

• Begin by listing primary differentials:
  • Carbuncle/Boil (most likely)
  • Simple skin abscess
  • Cellulitis without abscess
  • Infected sebaceous cyst
  • Consider hidradenitis suppurativa (less likely)
• Include red flag differentials:
  • Necrotising fasciitis (although unlikely given stable vitals)
  • Deep-seated abscess
• Explain confirmatory approach:
  • Clinical diagnosis primarily based on examination:
    • Fluctuant, tender swelling, with erythema and possible pus discharge.
    • No systemic features, such as fever or sepsis, reducing suspicion for more serious infection.
• Discuss when imaging might be required:
  • Ultrasound to differentiate abscess from cellulitis if uncertain.
  • Consider if the abscess is deep-seated or atypical in presentation.
• Acknowledge contributory factors:
  • Poorly controlled diabetes increases risk for recurrent infections and atypical presentations.

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Q2: Outline your management plan for John’s current condition.

The competent candidate should:

• Start with immediate management:
  • Perform incision and drainage (I&D) of the fluctuant lesion under aseptic conditions.
  • Local anaesthetic, sterile technique, and wound dressing.
  • Send pus swab for MCS (microscopy, culture, sensitivity).
• Discuss antibiotic therapy:
  • Empiric oral antibiotics targeting Staphylococcus aureus:
    • Flucloxacillin 500 mg QID for 5-7 days.
    • If penicillin allergic: Clindamycin or Trimethoprim-sulfamethoxazole.
  • Consider MRSA coverage depending on local resistance patterns and risk factors.
• Address diabetes control:
  • Optimise blood glucose control to aid healing.
  • Consider adjusting his diabetes management plan (may involve increasing metformin dose or adding another agent).
• Discuss follow-up:
  • Review in 48 hours to assess response and wound healing.
  • Plan for further diabetes follow-up.

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Q3: What preventive strategies would you recommend to John to reduce recurrence?

The competent candidate should:

• Address glycaemic control:
  • Explain its importance in reducing skin infection risk.
  • Refer to diabetes educator or endocrinologist.
• Promote skin hygiene:
  • Regular washing, especially after sweating.
  • Advise on clean clothing, avoiding skin trauma, and proper wound care.
• Encourage weight management and exercise:
  • Discuss potential benefits in improving insulin sensitivity and immune function.
• Discuss smoking cessation:
  • Offer Quitline referral or pharmacological aids like NRT or Varenicline.
• Review vaccination status:
  • Recommend influenza and COVID-19 vaccines.

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Q4: What factors increase John’s risk for complications, and how would you monitor him?

The competent candidate should:

• Identify risk factors:
  • Poorly controlled diabetes
  • Obesity (BMI 32)
  • Recurrent infections
  • Suboptimal personal hygiene due to work constraints
• Monitor for complications:
  • Signs of systemic infection (fever, chills)
  • Signs of necrotising fasciitis (increased pain out of proportion)
  • Persistent hyperglycaemia worsening wound healing
• Indicate hospital referral criteria:
  • Spreading cellulitis with systemic symptoms
  • Failed outpatient management or worsening infection
  • Need for intravenous antibiotics

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Q5: How would you address John’s diabetes management in this consultation?

The competent candidate should:

• Review current diabetes management:
  • HbA1c test (ordered)
  • Capillary glucose already elevated (15.2 mmol/L)
• Recommend optimising diabetes care:
  • Increase metformin dose (if tolerated)
  • Consider SGLT2 inhibitors or GLP-1 receptor agonists (weight loss benefit)
• Lifestyle advice:
  • Dietician referral for a diabetes-appropriate diet
  • Exercise plan tailored to his work and fitness level
• Arrange regular monitoring:
  • 3-monthly HbA1c
  • Annual diabetes cycle of care (foot checks, eye exams, renal function)
• Collaborative care:
  • Refer to diabetes educator
  • Discuss potential need for endocrinology referral

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SUMMARY OF A COMPETENT ANSWER

• Clear identification of likely diagnosis and red flag differentials.
• Evidence-based management plan, including I&D, antibiotics, and diabetes control.
• Comprehensive discussion of prevention strategies, tailored to patient needs.
• Recognition of complications and indications for escalation.
• Integration of diabetes management into the treatment plan.

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PITFALLS

• Failure to perform I&D, relying only on antibiotics.
• Ignoring glycaemic control, focusing only on the infection.
• Overlooking MRSA risk factors and inappropriate antibiotic choice.
• Missing signs of systemic illness or delaying hospital referral.
• Lack of follow-up plan, including wound care and diabetes review.

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REFERENCES

• RACGP Guidelines for Management of Skin Infections
• Therapeutic Guidelines: Antibiotic (eTG complete)
• Australian Diabetes Society Guidelines

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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 Obtains and records relevant information through history-taking, examination and investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Selects appropriate diagnostic options and interprets findings.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements an evidence-based management plan.

5. Preventive and Population Health

5.1 Identifies and advises on risk factors and prevention strategies.

6. Professionalism

6.1 Demonstrates ethical practice and professional behaviour.

7. General Practice Systems and Regulatory Requirements

7.1 Prescribes in accordance with regulatory requirements.

8. Procedural Skills

8.1 Performs procedures in line with current standards and guidelines.

9. Managing Uncertainty

9.1 Recognises and manages uncertainty in clinical presentations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious presentations and acts accordingly.

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Competency at Fellowship Level

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