CCE-CBD-074

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. Take a focused history to clarify the diagnosis and exclude red flags.

• Prompt: Explore joint symptoms (onset, distribution, trauma)
• Prompt: Enquire about systemic symptoms (fever, chills)
• Prompt: Ask about risk factors for gout (diet, alcohol, medications)

Q2. What are your differential diagnoses and what is your provisional diagnosis?

• Prompt: Discuss septic arthritis, crystal arthritis, and trauma
• Prompt: Explain reasoning for diagnosis of gout

Q3. Develop an acute and chronic management plan for Michael.

• Prompt: Discuss acute treatment (colchicine vs NSAIDs vs corticosteroids)
• Prompt: Plan for uric acid-lowering therapy after the acute episode
• Prompt: Address lifestyle changes (diet, alcohol, weight)

Q4. What preventive health strategies are appropriate for Michael?

• Prompt: Smoking cessation
• Prompt: Cardiovascular risk management (lipids, BP, CKD progression)
• Prompt: Vaccination updates if relevant

Q5. Discuss when and why you would refer Michael to a specialist.

• Prompt: Severe or recurrent gout
• Prompt: Suspected joint infection
• Prompt: Chronic tophaceous gout or impaired renal function requiring specialist input

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: Take a focused history to clarify the diagnosis and exclude red flags.

The competent candidate should:

• Begin by confirming onset, duration, and progression of the joint symptoms.
• Clarify the exact location of the pain (right first MTP joint), whether it’s mono- or poly-articular, and if there’s a history of previous episodes.
• Ask about systemic symptoms such as fever, chills, or rigors to help exclude septic arthritis.
• Explore any recent trauma or infections.
• Ask about dietary habits (purine-rich foods), alcohol consumption, and medication use (diuretics, NSAIDs).
• Explore family history of gout or metabolic conditions.
• Address impact on function and patient’s concerns (work implications, pain control).
• Inquire about comorbidities that might complicate management, including hypertension and CKD.

Q2: What are your differential diagnoses and what is your provisional diagnosis?

The competent candidate should:

• Recognise the most likely diagnosis as acute gout given the classic monoarthritis at the first MTP joint, sudden onset, and risk factors (diet, alcohol, family history, obesity).
• Provide differential diagnoses, including:
  • Septic arthritis (ruled out by absence of fever/systemic symptoms, low CRP)
  • Pseudogout (CPPD arthropathy, typically involves larger joints like the knee)
  • Trauma or fracture (unlikely without trauma history)
• Discuss the lack of tophi or polyarticular involvement suggesting an early-stage gout.

Q3: Develop an acute and chronic management plan for Michael.

The competent candidate should:

• Acute management:
  • Initiate colchicine (0.5mg bd) as first-line due to CKD (NSAIDs less ideal).
  • Consider oral corticosteroids (e.g., prednisolone 25-50mg daily) if colchicine contraindicated or ineffective.
  • Rest and ice the joint, provide analgesia.
• Chronic management:
  • Plan to start urate-lowering therapy (e.g., allopurinol) after acute flare settles.
  • Titrate allopurinol slowly due to CKD; monitor uric acid levels and renal function.
• Lifestyle modifications:
  • Counsel on reducing alcohol (especially beer), weight loss, and low-purine diet.
  • Encourage hydration and regular exercise.

Q4: What preventive health strategies are appropriate for Michael?

The competent candidate should:

• Address smoking cessation with pharmacological and behavioural support.
• Offer a CVD risk assessment (lipids, BP, renal function).
• Update vaccinations (influenza, pneumococcal if indicated).
• Discuss dietary advice for CKD and metabolic health.
• Offer chronic disease management plans (GPMP) and Team Care Arrangements (TCAs) for coordinated care (dietitian, exercise physiologist).

Q5: Discuss when and why you would refer Michael to a specialist.

The competent candidate should:

• Refer to a rheumatologist if:
  • Recurrent flares despite treatment
  • Diagnostic uncertainty (e.g., polyarthritis, atypical presentation)
  • Poor response or contraindications to standard treatments
• Refer to orthopaedic surgeon if chronic joint destruction occurs.
• Refer to renal physician for worsening CKD.
• Recognise the limited access in rural settings and plan for telehealth rheumatology consultations if applicable.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history excludes red flags and identifies gout risk factors.
• Differential diagnosis prioritises gout while ruling out septic arthritis.
• Evidence-based acute and chronic management, adjusted for CKD.
• Lifestyle advice addresses modifiable risk factors.
• Appropriate use of referrals and chronic disease planning.
• Clear communication, tailored to a rural health context.

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PITFALLS

• Failing to exclude septic arthritis when presented with acute monoarthritis.
• Prescribing NSAIDs without considering renal impairment.
• Starting allopurinol during an acute attack, worsening flare.
• Not addressing lifestyle factors (diet, alcohol, smoking).
• Missing opportunity for chronic disease management planning.
• Not recognising the need for specialist input in refractory gout.

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REFERENCES

• RACGP Guidelines for preventive activities in general practice (“Red Book”)
• National Institutes of Health on Rheumatology (Gout)
• Australian Family Physician (AFP) on Gout management in primary care

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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 Elicits appropriate clinical history informed by the patient’s context.
2.2 Performs a relevant physical examination and identifies signs of joint inflammation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes differential and provisional diagnoses with clear reasoning.
3.2 Justifies management decisions and explains reasoning.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops acute and chronic management plans based on evidence and guidelines.
4.2 Considers comorbidities and patient factors in therapy selection.

5. Preventive and Population Health

5.1 Addresses modifiable risk factors (diet, alcohol, smoking).

6. Professionalism

6.1 Provides respectful, ethical, and culturally appropriate care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses GPMPs and TCAs appropriately.

9. Managing Uncertainty

9.1 Identifies when further investigations or referrals are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on red flags requiring urgent care.

12. Rural Health Context (RH)

RH1.1 Provides care in resource-limited settings with telehealth when necessary.

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Competency at Fellowship Level

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