EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis for Ethan’s presentation?

• Prompt: Based on his history and examination, what are the most likely causes of his symptoms?
• Prompt: How would you differentiate between viral and bacterial infections?

Q2. What is the most appropriate management for Ethan at this stage?

• Prompt: How would you explain the likely viral nature of his illness?
• Prompt: What symptomatic treatment options would you recommend?

Q3. Ethan is concerned about whether he needs antibiotics. How would you address his concern?

• Prompt: How would you educate the patient about the appropriate use of antibiotics?
• Prompt: How would you explain the risks of unnecessary antibiotic use?

Q4. What red flags would prompt further investigation or escalation of care?

• Prompt: What features in his history or examination might suggest a more serious condition?
• Prompt: When would you consider ordering blood tests or imaging?

Q5. What preventive health advice would you provide to Ethan?

• Prompt: What vaccination advice would be relevant for him?
• Prompt: What general lifestyle measures can help reduce the risk of future infections?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis for Ethan’s presentation?

Answer:

Ethan presents with fatigue, sore throat, headache, low-grade fever, and myalgia. Given the history and examination findings, the differential diagnosis includes:

Most Likely Diagnoses:

1. Viral Upper Respiratory Tract Infection (URTI) – The most common cause, typically self-limiting, with symptoms resolving in 7–10 days.
2. Influenza – Sudden onset of fever, myalgia, headache, and fatigue supports this. Testing may be considered if clinically indicated.
3. COVID-19 – Despite vaccination, breakthrough infections are possible. Testing is warranted per current public health guidelines.
4. Infectious Mononucleosis (EBV/CMV) – Persistent fatigue, pharyngitis, and lymphadenopathy raise suspicion. A Monospot test may be useful if clinically indicated.

Less Likely Diagnoses:

5. Streptococcal Pharyngitis – Less likely due to absence of exudates, cervical lymphadenopathy, and high fever, but should be considered if symptoms worsen.
6. Mycoplasma Pneumoniae Infection – Causes atypical pneumonia; would be more likely if there were a persistent dry cough.
7. Bacterial Sinusitis – More likely if symptoms persist >10 days, or there is worsening facial pain and purulent nasal discharge.

Distinguishing Viral vs Bacterial Infections:

• Viral infections: Typically gradual onset, low-grade fever, generalised symptoms, self-limiting course.
• Bacterial infections: More abrupt onset, high fever (>38.5°C), localised symptoms (exudative tonsillitis, unilateral sinus tenderness), often require antibiotics.

Further testing (e.g., FBC, throat swab, COVID-19 PCR, Monospot test) should be considered if symptoms persist, worsen, or suggest an alternative diagnosis.

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Q2: What is the most appropriate management for Ethan at this stage?

Answer:

Given the high likelihood of a viral infection, the focus is on supportive care and patient education.

Patient Education:

• “Your symptoms suggest a viral illness, which usually resolves on its own within 7-10 days.”
• “Rest, hydration, and symptomatic management will help your recovery.”

Symptomatic Management:

1. Pain and fever relief – Paracetamol or ibuprofen as needed.
2. Hydration – Encourage adequate fluid intake to prevent dehydration.
3. Rest – Advise reduced activity until symptoms improve.
4. Throat relief – Saltwater gargles, honey, lozenges, or throat sprays.
5. Nasal congestion – Steam inhalation, saline nasal sprays, or short-term decongestants.

Red Flags for Follow-up:

• Persistent fever >5 days or worsening symptoms.
• Difficulty swallowing, drooling, stridor (suggestive of epiglottitis).
• Severe headache with neck stiffness (suggesting meningitis).
• Worsening cough or shortness of breath (suggesting pneumonia).

Investigations (FBC, throat swab, Monospot test) should be considered if symptoms persist or worsen.

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Q3: Ethan is concerned about whether he needs antibiotics. How would you address his concern?

Answer:

1. Acknowledge His Concern:

• “I understand you’re feeling unwell and want to recover quickly. Many people think antibiotics will help, but they are only effective for bacterial infections, not viral ones like yours.”

2. Explain Why Antibiotics Are Not Needed:

• “Your symptoms strongly suggest a viral infection, which resolves on its own. Antibiotics won’t speed up recovery or prevent complications.”

3. Educate on Risks of Unnecessary Antibiotics:

• Side effects – Including diarrhoea, nausea, and allergic reactions.
• Antibiotic resistance – Overuse leads to reduced effectiveness in the future.
• Gut flora disruption – Causing digestive issues.

4. Safety-Netting Advice:

• “If your symptoms worsen or you develop new concerning signs like persistent high fever, difficulty swallowing, or shortness of breath, please return for review.”

Providing written resources or linking to reputable sites (e.g., NPS MedicineWise, RACGP Guidelines) reinforces key messages.

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Q4: What red flags would prompt further investigation or escalation of care?

Answer:

Red flags warranting urgent reassessment include:

History & Examination Features Suggesting Serious Illness:

• High fever (>38.5°C) for >5 days – Suggests possible bacterial infection.
• Severe sore throat with difficulty swallowing, drooling, or stridor – Consider epiglottitis or peritonsillar abscess.
• Persistent or worsening cough, shortness of breath, or chest pain – Possible pneumonia or myocarditis.
• Worsening headache, neck stiffness, photophobia – Concern for meningitis.
• New-onset rash with systemic symptoms – Consider meningococcal disease.

Indications for Investigations:

• FBC, CRP – If a bacterial infection is suspected.
• Throat swab (Strep test) – If Centor score suggests bacterial pharyngitis.
• COVID-19/Influenza PCR – If symptoms align with testing criteria.
• Monospot test – If considering infectious mononucleosis.

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Q5: What preventive health advice would you provide to Ethan?

Answer:

1. Vaccination
   • Annual influenza vaccine to reduce risk of severe illness.
   • COVID-19 booster if due.
   • Consider pertussis booster if needed.
2. Hand Hygiene and Respiratory Etiquette
   • Frequent handwashing to reduce transmission.
   • Covering coughs and sneezes to prevent spreading illness.
3. Healthy Lifestyle
   • Balanced diet with adequate vitamins (C, D, zinc).
   • Regular exercise to support immune function.
   • Adequate sleep and stress management.
4. Minimise Close Contact When Unwell
   • Stay home when symptomatic.
   • Avoid contact with vulnerable individuals (elderly, immunocompromised).

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SUMMARY OF A COMPETENT ANSWER

• Provides a structured differential diagnosis with reasoning.
• Uses evidence-based guidelines to justify antibiotic avoidance.
• Explains red flags and follow-up clearly.
• Offers practical preventive health strategies.

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PITFALLS

• Over-prescribing antibiotics without justification.
• Failing to recognise red flags requiring escalation.
• Not addressing patient concerns empathetically.
• Omitting preventive health advice.

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REFERENCES

• PCH – PCH Guidelines for Acute Respiratory Infections
• GP Exams – Viral disease, other/NOS

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MARKING

Each competency area is assessed on a 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