EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Michael’s symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for further investigations?

• Prompt: What symptoms or findings would warrant cardiovascular or endocrine assessment?
• Prompt: What initial investigations would be appropriate?

Q3. How would you manage Michael’s condition?

• Prompt: What lifestyle modifications and non-pharmacological options would you recommend?
• Prompt: When would you consider pharmacological therapy?

Q4. Michael is concerned that his erectile dysfunction is a sign of heart disease. How would you counsel him?

• Prompt: How would you explain the link between erectile dysfunction and cardiovascular risk?
• Prompt: What follow-up strategies would you implement?

Q5. What preventive strategies can Michael implement to improve his sexual health?

• Prompt: What lifestyle changes are most effective?
• Prompt: When should he seek further medical review?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Michael’s symptoms?

Michael’s most likely diagnosis is erectile dysfunction (ED), with contributing factors including hypertension, SSRI use, smoking, alcohol, and psychological stress. His symptoms have been gradual in onset, associated with reduced morning erections, suggesting a likely organic cause with possible psychological overlay.

Key Differential Diagnoses:

1. Organic Erectile Dysfunction
   • Vascular – Hypertension, smoking, obesity (endothelial dysfunction).
   • Endocrine – Hypogonadism, diabetes, thyroid dysfunction.
   • Neurological – Multiple sclerosis, Parkinson’s, spinal cord injury.
   • Medication-induced – Sertraline, antihypertensives, alcohol.
2. Psychogenic Erectile Dysfunction
   • Performance anxiety, depression, relationship stress.
   • More likely if sudden onset, situational, or nocturnal/masturbatory erections are preserved.
3. Mixed Organic and Psychogenic ED
   • Common in middle-aged men with vascular risk factors and stress.

Further history and investigations will guide diagnosis.

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Q2: What red flags would indicate the need for further investigations?

Red flags requiring further evaluation:

• Sudden-onset severe ED – Consider neurological disease or medication side effects.
• Loss of secondary sexual characteristics (e.g., reduced body hair, testicular atrophy) – Suggests hypogonadism.
• Severe fatigue, weight loss, or polyuria/polydipsia – Screen for diabetes, thyroid dysfunction, or malignancy.
• Persistent ED despite treatment – May warrant specialist referral.

Recommended Investigations:

• Fasting glucose & HbA1c – Diabetes screening.
• Lipid profile & blood pressure assessment – Cardiovascular risk assessment.
• Morning testosterone & prolactin – Hypogonadism or hyperprolactinaemia.
• TSH & Free T4 – Thyroid dysfunction.

A structured cardiovascular risk assessment is also critical, given ED may be an early marker of cardiovascular disease.

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Q3: How would you manage Michael’s condition?

Lifestyle and Non-Pharmacological Interventions:

• Smoking cessation – Reduces vascular dysfunction and improves nitric oxide availability.
• Weight loss and exercise – Improves endothelial function and testosterone levels.
• Limit alcohol intake – Excess alcohol worsens libido and erectile function.
• Stress management – Referral for psychologist or couples counselling if needed.

Medication Review and Adjustments:

• Sertraline (SSRI-related ED) – Consider dose reduction or switch to bupropion or mirtazapine if appropriate.
• Blood pressure management – ACE inhibitors or calcium channel blockers may have less impact on ED than beta-blockers.

Pharmacological Therapy (if needed):

• PDE5 inhibitors (e.g., sildenafil 50mg PRN, tadalafil 5mg daily) – First-line treatment if no contraindications.
• Testosterone replacement – If hypogonadism is confirmed.

Follow-up is essential to monitor response and adjust management.

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Q4: Michael is concerned that his erectile dysfunction is a sign of heart disease. How would you counsel him?

1. Acknowledge his concerns
   • “Erectile dysfunction can be an early warning sign of cardiovascular disease.”
2. Explain the Link Between ED and Heart Health
   • “ED is often linked to reduced blood flow due to atherosclerosis.”
   • “We need to assess your overall cardiovascular risk and address modifiable factors.”
3. Reassure and Offer a Plan
   • “This doesn’t mean you have heart disease now, but it’s an opportunity to improve long-term heart health.”
   • “Let’s focus on optimising blood pressure, cholesterol, smoking cessation, and exercise.”
4. Follow-up and Ongoing Risk Reduction
   • Regular monitoring of blood pressure, lipid profile, and metabolic health.
   • Cardiologist referral if significant cardiovascular risk is detected.

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Q5: What preventive strategies can Michael implement to improve his sexual health?

1. Cardiovascular and Metabolic Health Optimisation:
   • Quit smoking and reduce alcohol intake.
   • Regular exercise (150 minutes/week) and weight management.
   • Blood pressure and lipid control.
2. Lifestyle and Relationship Strategies:
   • Address stress and anxiety (psychotherapy, mindfulness).
   • Improve sleep hygiene, as poor sleep can lower testosterone.
   • Open communication with his partner about expectations and emotional concerns.
3. Regular Health Checks:
   • Annual cardiovascular and diabetes risk assessment.
   • Regular review of medication side effects and adjustments as needed.

Encouraging proactive health changes can improve both erectile function and overall well-being.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, considering vascular, endocrine, neurological, and psychogenic causes.
• Identification of red flags requiring further investigations.
• Structured management plan, including lifestyle changes, pharmacotherapy, and psychological interventions.
• Clear patient-centred counselling, addressing concerns about cardiovascular disease.
• Preventive strategies focused on cardiovascular health, relationship dynamics, and psychological support.

PITFALLS

• Not addressing cardiovascular risk, missing an opportunity for early intervention.
• Overlooking medication side effects, particularly SSRI-related sexual dysfunction.
• Focusing solely on pharmacological treatment, neglecting lifestyle and psychological factors.
• Failing to assess relationship impact, which may affect adherence to management plans.
• Lack of structured follow-up, missing progression or treatment side effects.

REFERENCES

• RACGP – RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• GP Exams – Sexual function symptom/complaint (male)

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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 Creates a safe and non-judgemental space to discuss sexual health concerns.
1.2 Uses open-ended questions to explore the impact of symptoms on quality of life and relationships.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough sexual and medical history, including psychological and lifestyle factors.
2.2 Identifies red flags that may indicate underlying systemic disease.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between psychogenic and organic erectile dysfunction.
3.2 Identifies potential causes, including cardiovascular, hormonal, neurological, and medication-related factors.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan based on underlying aetiology.
4.2 Considers lifestyle, pharmacological, and psychological interventions.

5. Preventive and Population Health

5.1 Provides education on modifiable risk factors and preventive strategies for sexual health.

6. Professionalism

6.1 Demonstrates empathy and sensitivity in discussing intimate health concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up to monitor treatment response.

9. Managing Uncertainty

9.1 Recognises when specialist referral (e.g., urologist, endocrinologist, psychologist) is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies when erectile dysfunction may be a marker for cardiovascular disease.

Competency at Fellowship Level

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