EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess James’ respiratory condition?

• Prompt: What red flag symptoms should be explored?
• Prompt: How would you assess asthma control in this context?

Q2. What are the most likely differential diagnoses, and how would you differentiate them?

• Prompt: How would you differentiate viral bronchitis, bacterial pneumonia, and asthma exacerbation?
• Prompt: What role do investigations play in guiding diagnosis?

Q3. What is your management plan for James, including pharmacological and non-pharmacological approaches?

• Prompt: Would you prescribe antibiotics? Why or why not?
• Prompt: What role does asthma optimisation play in this case?

Q4. What advice would you provide James regarding self-care and monitoring for complications?

• Prompt: What red flag symptoms require urgent review?
• Prompt: How would you counsel him on smoking cessation?

Q5. James returns in three days with worsening dyspnoea and persistent fever. What would you do next?

• Prompt: What changes to management would you consider?
• Prompt: When is hospital referral appropriate?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess James’ respiratory condition?

A comprehensive history is essential to assess James’ condition and identify potential red flags.

1. Symptom Progression and Severity:

• Onset and duration of cough, fever, and breathlessness.
• Nature of cough: Productive or dry, colour and consistency of sputum.
• Fever pattern: Persistent or resolving.
• Shortness of breath: At rest or with exertion.
• Associated symptoms: Chest pain, haemoptysis, confusion, fatigue.

2. Red Flag Symptoms:

• Signs of severe infection: High fever, rigors, night sweats.
• Respiratory distress: Accessory muscle use, inability to speak in full sentences.
• Haemoptysis or pleuritic chest pain.

3. Asthma History and Control:

• Frequency of wheezing, night-time symptoms, exercise intolerance.
• Preventer use and adherence.
• History of hospitalisations, ICU admissions, previous intubation.

4. Smoking and Environmental Exposures:

• Pack-year history, readiness for cessation.
• Exposure to dust, chemicals, or workplace irritants.

5. Vaccination Status:

• Influenza, pneumococcal, and COVID-19 vaccinations.

A thorough history will help differentiate between viral bronchitis, bacterial pneumonia, or asthma exacerbation.

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Q2: What are the most likely differential diagnoses, and how would you differentiate them?

James’ presentation suggests a lower respiratory tract infection (LRTI) with possible asthma exacerbation.

1. Acute Viral Bronchitis:

• Common cause, usually self-limiting.
• Cough >5 days, clear or yellow sputum, low-grade fever.
• No focal chest signs on examination.

2. Bacterial Pneumonia:

• Fever >38°C, productive cough with purulent sputum.
• Localised lung crackles, dullness to percussion.
• CRP >100, CXR showing consolidation.

3. Asthma Exacerbation:

• Wheezing, increased salbutamol use, diurnal variation.
• History of poor adherence to preventer therapy.

Investigations to Differentiate:

• CXR: Consolidation suggests pneumonia.
• FBC/CRP: Raised WCC and CRP >100 suggests bacterial infection.
• Sputum culture: If bacterial pneumonia suspected.

Early differentiation guides appropriate treatment and antibiotic stewardship.

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Q3: What is your management plan for James, including pharmacological and non-pharmacological approaches?

James’ management will be individualised based on severity.

1. Supportive Care:

• Adequate hydration, rest, paracetamol for fever.
• Saline nasal spray, steam inhalation for symptom relief.

2. Pharmacological Management:

• Salbutamol via spacer: 4-6 puffs every 4 hours as needed.
• ICS/LABA combination: Budesonide-formoterol to improve asthma control.
• Antibiotics if bacterial pneumonia suspected:
  • Amoxicillin-clavulanate 875/125mg BD for 5-7 days OR
  • Doxycycline 100mg BD for 5-7 days (if penicillin allergy).

3. Preventive Measures:

• Influenza and pneumococcal vaccination.
• Smoking cessation counselling, referral to Quitline.

4. Safety-Netting and Follow-Up:

• Red flag symptoms requiring review: worsening dyspnoea, chest pain, persistent fever.
• Review in 48 hours to assess response.

Timely intervention improves symptom control and reduces complications.

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Q4: What advice would you provide James regarding self-care and monitoring for complications?

James requires clear education and safety-netting strategies.

1. Symptom Management:

• Fluids, rest, and over-the-counter analgesics.
• Salbutamol as needed but seek review if requiring excessive doses.

2. Red Flag Symptoms for Urgent Review:

• Breathlessness worsening at rest.
• Coughing up blood or worsening chest pain.
• Persistent fever >48 hours despite treatment.

3. Smoking Cessation:

• Explain smoking’s impact on respiratory health and recurrent infections.
• Offer NRT, referral to Quitline, motivational interviewing.

4. Preventive Strategies:

• Annual flu vaccine, pneumococcal vaccine, asthma action plan.

Empowering patients with knowledge improves adherence and outcomes.

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Q5: James returns in three days with worsening dyspnoea and persistent fever. What would you do next?

James’ deterioration suggests treatment failure or disease progression.

1. Reassess for Complications:

• Repeat examination: New lung findings may indicate worsening pneumonia.
• Check SpO₂: If <92%, hospitalisation is warranted.

2. Repeat Investigations:

• CXR: Assess for consolidation or pleural effusion.
• CRP/WCC: Persistent elevation suggests ongoing infection.

3. Escalate Treatment:

• Consider stronger antibiotics (e.g., IV ceftriaxone + azithromycin) if worsening.
• Optimise asthma treatment with prednisolone 40mg for 5 days if exacerbation.

4. Indications for Hospital Referral:

• SpO₂ <92%, respiratory distress, or sepsis.
• Persistent hypoxia despite bronchodilators.

Early intervention can prevent serious complications such as sepsis or respiratory failure.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking covering symptom progression, asthma control, and red flags.
• Systematic differentiation between viral bronchitis, pneumonia, and asthma exacerbation.
• Evidence-based management including antibiotic stewardship and asthma optimisation.
• Clear safety-netting and follow-up plans to prevent complications.
• Preventive healthcare focus on vaccination and smoking cessation.

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PITFALLS

• Failure to consider pneumonia in a high-risk patient with worsening symptoms.
• Overprescription of antibiotics without clear bacterial infection.
• Inadequate asthma management, missing an opportunity for long-term control.
• Poor safety-netting, failing to educate on when to seek urgent care.
• Not addressing smoking cessation, missing a key modifiable risk factor.

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REFERENCES

• RACGP – RACGP Asthma Management Guidelines
• GP Exams – Respiratory tract infection

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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 Communicates effectively with the patient regarding symptoms and management.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough history and examination for respiratory illness.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between viral, bacterial, and asthma-related conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Implements appropriate treatment strategies, balancing risks and benefits.

Competency at Fellowship Level

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