CCE-CBD-150.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses and how would you prioritise them?

A competent candidate would approach this question by identifying the most likely differentials based on Lisa’s presentation, clinical findings, and risk factors.

Top differential diagnoses:

• Primary hypothyroidism: Most likely given Lisa’s fatigue, weight gain, constipation, hair thinning, cold intolerance, and family history of autoimmune thyroid disease. Clinical findings of dry skin, bradycardia, and delayed reflexes support this.
• Iron deficiency anaemia (recurrent): History of iron deficiency anaemia. Fatigue and cognitive symptoms may point towards recurrence. Needs exclusion.
• Depression/anxiety: Symptoms of fatigue and poor concentration could overlap with a mood disorder. However, her physical signs suggest an organic cause.
• Chronic fatigue syndrome: Less likely but could be a consideration in prolonged fatigue without clear explanation.
• Early type 2 diabetes mellitus: Family history present; less likely to explain all symptoms but requires exclusion.

Prioritisation reasoning:

• Primary hypothyroidism is prioritised due to its prevalence, the congruence of symptoms, family history, and examination findings.
• Iron deficiency anaemia and depression/anxiety are important differentials due to overlapping symptoms.
• Screening for diabetes is reasonable due to family history and overweight BMI.

Q2: What investigations would you order or review to clarify the diagnosis?

Investigations focus on confirming hypothyroidism and ruling out differentials.

• Thyroid function tests (TFTs): TSH and free T4. First-line tests for suspected hypothyroidism.
• Anti-thyroid peroxidase antibodies (anti-TPO): To assess for autoimmune thyroiditis (Hashimoto’s thyroiditis).
• Full blood count (FBC): To assess for anaemia.
• Iron studies: To assess for iron deficiency anaemia recurrence.
• Vitamin B12/folate levels: To exclude other causes of fatigue and cognitive dysfunction.
• Fasting glucose/HbA1c: Due to family history and overweight status.
• Lipid profile: Hypothyroidism can cause dyslipidaemia.
• Electrolytes and renal function: Baseline before starting thyroid replacement therapy.

Q3: How would you explain the potential diagnosis of hypothyroidism to Lisa, including management options?

Use patient-centred communication, addressing Lisa’s concerns.

Explanation:

• Hypothyroidism is a condition where the thyroid gland doesn’t produce enough hormones, causing symptoms like fatigue, weight gain, constipation, and cold intolerance.
• It’s common, particularly in women and often runs in families, like Lisa’s mother’s history.
• Autoimmune thyroiditis is the most common cause.

Management:

• Thyroxine replacement therapy (levothyroxine): A daily tablet to restore hormone levels. Dosing is individualised and guided by blood tests.
• Monitoring: Regular follow-up for TSH levels, especially after starting treatment.
• Symptoms usually improve over weeks to months with proper treatment.
• Lifestyle advice: Healthy diet, exercise, and weight management.
• Address concerns about rural access with telehealth and local pathology services for follow-up.

Q4: How would you address Lisa’s concerns about living in a rural area and accessing healthcare?

Strategies:

• Telehealth consultations for follow-ups and dose adjustments.
• Pathology services: Use local collection centres for blood tests.
• Education: On symptoms to monitor and when to seek review.
• Shared care with local allied health or nurse practitioners.
• Safety netting: Clear instructions on medication adherence and when to report side effects or deterioration.

Q5: What preventive health activities should be considered during this consultation?

Preventive care includes:

• Cardiovascular risk assessment: Check BP, lipids, glucose/HbA1c, given hypothyroidism’s link to dyslipidaemia.
• Weight management: Dietitian referral for weight control.
• Physical activity: Encourage regular exercise tailored to symptoms.
• Cervical screening: Confirm up-to-date status.
• Mental health: Screen for depression/anxiety, as hypothyroidism can affect mood.
• Vaccinations: Check influenza, COVID-19, and pneumococcal vaccination status if indicated.

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SUMMARY OF A COMPETENT ANSWER

• Thorough differential diagnoses, prioritising hypothyroidism based on history and exam.
• Appropriate investigations to confirm diagnosis and exclude other conditions.
• Clear, empathetic explanation of hypothyroidism and its management.
• Addressing rural health challenges with telehealth and local services.
• Comprehensive preventive care including cardiovascular risk and mental health screening.

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PITFALLS

• Failure to consider differentials beyond hypothyroidism, such as anaemia or depression.
• Not tailoring the explanation to Lisa’s rural context, ignoring access issues.
• Omitting lifestyle advice or preventive health measures.
• Inadequate safety netting and follow-up planning.
• Overlooking psychosocial factors, including stress from work and family.

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REFERENCES

• RACGP Guidelines on Hypothyroidism Management in General Practice
• Therapeutic Guidelines: Endocrinology
• Australian Thyroid Foundation

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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 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.

5. Preventive and Population Health

5.1 Provides counselling on modifiable risk factors and behaviours.

6. Professionalism

6.1 Adopts a patient-centred approach in complex and challenging situations.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care effectively.

8. Procedural Skills

8.1 Performs procedural skills safely.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty and patient expectations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages severe acute and chronic health conditions.

Competency at Fellowship Level

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