EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess Liam’s respiratory symptoms?

• Prompt: What factors help differentiate asthma from other causes of wheezing?
• Prompt: How would you assess symptom severity and triggers?

Q2. What are the most likely diagnoses, and how would you confirm the diagnosis?

• Prompt: What clinical features support a diagnosis of asthma?
• Prompt: What role does spirometry or peak flow testing play in this age group?

Q3. Outline an initial management plan, including an asthma action plan.

• Prompt: When would you initiate preventer therapy?
• Prompt: How would you educate the family on asthma management?

Q4. What advice would you provide regarding trigger avoidance and preventive care?

• Prompt: What environmental triggers should be minimised?
• Prompt: What vaccinations and general health measures are recommended?

Q5. Liam returns in two months with ongoing night-time symptoms despite preventer therapy. What would you do next?

• Prompt: How would you assess treatment adherence and response?
• Prompt: When is referral to a paediatric respiratory specialist warranted?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess Liam’s respiratory symptoms?

A detailed history is essential to determine whether Liam has asthma and assess symptom severity.

1. Symptom Characteristics:

• Onset, duration, and frequency of wheezing and breathlessness.
• Triggers: Viral infections, exercise, cold air, allergens, smoke exposure.
• Night-time symptoms: Frequency of waking with cough or wheeze.
• Exercise tolerance: Ability to play and participate in activities.

2. Previous Episodes and Severity:

• Number of episodes in the past year.
• Use of salbutamol: Frequency, effectiveness, and need for urgent care.
• History of hospital visits, oral steroid use, or ICU admission.

3. Family and Personal Medical History:

• Family history of asthma, eczema, hay fever.
• History of eczema or allergic rhinitis.

4. Environmental and Lifestyle Factors:

• Passive smoke exposure, mould, pets.
• Daycare or school attendance.

A structured history helps confirm asthma diagnosis and determine severity.

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Q2: What are the most likely diagnoses, and how would you confirm the diagnosis?

Liam’s symptoms are suggestive of asthma, but differentials should be considered.

1. Most Likely Diagnoses:

• Asthma: Recurrent wheezing, night-time symptoms, exercise limitation.
• Viral-induced wheeze: If symptoms only occur during infections.
• Allergic rhinitis-associated cough: If symptoms are seasonal or triggered by allergens.

2. Supporting Features for Asthma Diagnosis:

• Symptom variability: Worse at night, improves with bronchodilator.
• History of recurrent wheezing episodes.
• Family history of atopy.

3. Diagnostic Tests:

• Spirometry (if feasible): Reversible airway obstruction with bronchodilator response.
• Peak expiratory flow (PEF) monitoring: Variability over time.

A clinical diagnosis is often made in children based on history and response to treatment.

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Q3: Outline an initial management plan, including an asthma action plan.

Liam’s symptoms suggest persistent asthma, requiring preventer therapy and education.

1. Medication Management:

• Reliever (Salbutamol 100mcg via spacer, 2 puffs PRN).
• Initiate low-dose inhaled corticosteroid (ICS): Fluticasone or budesonide daily.
• Monitor response over 6 weeks.

2. Asthma Action Plan:

• Green Zone: No symptoms → Reliever PRN.
• Yellow Zone: Worsening symptoms → Increase reliever, monitor closely.
• Red Zone: Severe distress → Seek urgent medical care.

3. Education:

• Demonstrate correct inhaler technique.
• Use a spacer device for better drug delivery.
• Explain the role of preventers vs relievers.

4. Follow-Up:

• Review in 4-6 weeks to assess symptom control and adherence.

An individualised plan ensures asthma control and reduces exacerbations.

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Q4: What advice would you provide regarding trigger avoidance and preventive care?

Preventing exacerbations is key to long-term asthma control.

1. Trigger Avoidance:

• Minimise allergen exposure: Avoid dust, pets, mould.
• Avoid passive smoke exposure.
• Monitor weather changes (cold air triggering symptoms).

2. Infection Prevention:

• Annual influenza vaccination.
• Ensure COVID-19 vaccination is up to date.

3. General Health and Lifestyle:

• Encourage regular exercise while using reliever pre-exercise.
• Maintain a healthy weight.

4. Parental Monitoring and Early Intervention:

• Recognise early symptoms and act according to the asthma action plan.

Clear preventive measures reduce the risk of asthma attacks.

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Q5: Liam returns in two months with ongoing night-time symptoms despite preventer therapy. What would you do next?

Liam’s persistent symptoms despite treatment require further assessment.

1. Assess Treatment Adherence and Technique:

• Confirm regular ICS use (compliance issues are common).
• Observe inhaler technique with spacer.
• Assess for overuse of reliever medication.

2. Consider Alternative Diagnoses or Modifying Therapy:

• Allergic rhinitis contributing to night-time symptoms? Consider antihistamines or nasal corticosteroids.
• Step up therapy: Increase ICS dose or consider adding leukotriene receptor antagonist (montelukast).

3. When to Refer to a Specialist:

• Frequent exacerbations requiring steroids.
• Poor control despite high-dose ICS.
• Suspected complex or atypical asthma.

4. Ongoing Monitoring:

• Review asthma action plan and reinforce education.
• Regular follow-up to adjust treatment as needed.

Ensuring optimal management prevents worsening symptoms and improves quality of life.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking covering symptom frequency, severity, and triggers.
• Clinical diagnosis of asthma, supported by reversible symptoms and response to bronchodilators.
• Stepwise management, including preventer therapy and an asthma action plan.
• Education on inhaler technique, symptom monitoring, and trigger avoidance.
• Timely follow-up and referral if symptoms remain uncontrolled.

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PITFALLS

• Failure to assess inhaler technique and adherence, leading to suboptimal treatment response.
• Not considering alternative diagnoses, such as allergic rhinitis or recurrent viral-induced wheeze.
• Delaying initiation of preventer therapy, leading to ongoing symptoms.
• Over-reliance on reliever medication, instead of optimising preventer therapy.
• Not providing an asthma action plan, leaving parents unprepared for exacerbations.

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REFERENCES

• RACGP – RACGP Guidelines on Asthma Management
• GP Exams – Asthma
  

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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

Competency at Fellowship Level

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