CCE-CBD-192

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between gastrointestinal, neurological, metabolic, and pregnancy-related causes?
• Prompt: What features would make you concerned about an underlying serious condition?

Q2. What are your initial management steps?

• Prompt: What investigations are required at this stage?
• Prompt: When would you refer for specialist review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address her concerns about pregnancy?
• Prompt: What lifestyle modifications and pharmacological treatments would you recommend?

Q4. What preventive measures can help reduce her symptoms and improve well-being?

• Prompt: What dietary and lifestyle changes could help?
• Prompt: When should she seek further medical review?

Q5. What are the red flags that would necessitate urgent referral?

• Prompt: What clinical features suggest a high risk of serious pathology?
• Prompt: How would you manage a patient with refractory nausea?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Nausea is a non-specific symptom with a broad differential, requiring a systematic approach to identify benign, metabolic, neurological, and gastrointestinal causes.

Differential Diagnoses:

1. Pregnancy-related nausea (Most Likely Diagnosis)
   • Key features: Morning nausea, occasional vomiting, early pregnancy suspicion.
   • Sexually active, oral contraceptive use (failure possible).
2. Gastrointestinal Causes
   • Gastro-oesophageal reflux disease (GORD): Post-meal nausea, heartburn.
   • Gastritis/peptic ulcer disease: History of NSAID use, epigastric pain.
3. Neurological Causes
   • Migraine-associated nausea: Often with headache, photophobia.
   • Raised intracranial pressure (ICP): Persistent nausea, worse in the morning, neurological symptoms.
4. Metabolic and Endocrine Causes
   • Thyroid dysfunction: Hyperthyroidism or hypothyroidism can cause nausea.
   • Electrolyte disturbances (hyponatraemia, hypercalcaemia).
5. Psychogenic Causes
   • Anxiety-related nausea: History of mild anxiety, stress at work.

Most Likely Diagnosis:

• Pregnancy-related nausea (early pregnancy) given morning nausea, fatigue, and sexually active status.
• Requires confirmation with urine pregnancy test.

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Q2: What are your initial management steps?

Answer:

1. Investigations to Confirm Diagnosis

• Urine pregnancy test (UPT) – If positive, confirm gestation and discuss prenatal care.
• Blood tests:
  • FBC, UECs (dehydration, metabolic abnormalities).
  • Thyroid function tests (TSH, free T4 for thyroid dysfunction).
  • LFTs, lipase (rule out liver/pancreatic pathology if persistent).

2. Symptomatic Management

• Lifestyle measures:
  • Eat small, frequent meals and avoid triggers (spicy/fatty foods).
  • Ginger supplements, acupressure wristbands.
• Pharmacological therapy (if severe):
  • Pyridoxine (vitamin B6) ± doxylamine (first-line for pregnancy-related nausea).
  • Metoclopramide or ondansetron if persistent.

3. Referral Criteria

• Gynaecology referral if hyperemesis gravidarum suspected.
• Gastroenterology referral if GORD or peptic ulcer suspected.
• Neurology referral if neurological red flags present.

4. Follow-Up Plan

• Review in 1-2 weeks for symptom progression.
• Early pregnancy care if UPT positive.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms are consistent with pregnancy-related nausea. This is common in early pregnancy and usually resolves by the second trimester.”
• “We need to confirm this with a pregnancy test, and if positive, plan for early prenatal care.”

Treatment Plan:

• “You can start with dietary changes (small meals, avoiding triggers) and vitamin B6 supplementation.”
• “If nausea worsens, we can try safe anti-nausea medications.”

Safety-Netting:

• “If you develop severe vomiting, dehydration, or weight loss, return urgently.”
• “If your pregnancy test is negative, we will explore other causes and follow up.”

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Q4: What preventive measures can help reduce her symptoms and improve well-being?

Answer:

• Dietary modifications:
  • Avoid spicy, fatty, or strong-smelling foods.
  • Eat small, frequent meals to prevent gastric irritation.
• Hydration and Supplements:
  • Increase water intake (especially if vomiting).
  • Consider ginger, vitamin B6, acupressure for symptom relief.
• Lifestyle Adjustments:
  • Reduce stress, improve sleep, light exercise.
  • Prenatal vitamins (if pregnancy confirmed).
• Early Medical Review:
  • If nausea persists beyond 12 weeks or worsens, review urgently.

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Q5: What are the red flags that would necessitate urgent referral?

Answer:

• Severe, persistent vomiting (hyperemesis gravidarum).
• Dehydration, electrolyte imbalance, weight loss.
• Neurological symptoms (headache, visual disturbance – raised ICP).
• Abdominal pain, jaundice, or haematemesis (liver, gastric pathology).
• New onset of severe anxiety or depression.

Urgent Management:

• Hospital referral for IV fluids if severe dehydration.
• Specialist referral (obstetrics, gastroenterology, neurology) if red flags present.

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SUMMARY OF A COMPETENT ANSWER

• Correctly identifies pregnancy-related nausea as the most likely cause.
• Orders appropriate investigations (pregnancy test, blood tests).
• Provides a structured management plan, including lifestyle and pharmacological options.
• Effectively explains the condition, addressing patient concerns.
• Identifies red flags requiring urgent referral.

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PITFALLS

• Failing to consider pregnancy as a differential diagnosis.
• Over-investigating without clinical justification.
• Not addressing the patient’s concerns about pregnancy.
• Missing red flags for serious conditions.
• Delaying referral for hyperemesis gravidarum or concerning neurological symptoms.

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REFERENCES

• RACGP Guidelines – Gastrointestinal Disorders
• GP Exams – Nausea

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to nausea.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between gastrointestinal, neurological, metabolic, and pregnancy-related causes.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including lifestyle and pharmacological interventions.
4.2 Recognises when further investigations or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on dietary modifications and hydration strategies.

Competency at Fellowship Level

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