CCE-CBD-038

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the main differential diagnoses to consider for Jane’s symptoms?

• Prompt: Discuss the potential causes of her symptoms, including psychological, menopausal, and any other relevant factors.
• Prompt: How might Jane’s presentation be impacted by her social circumstances?

Q2. What initial management strategies would you suggest for Jane’s menopausal symptoms and sexual dysfunction?

• Prompt: Include both non-pharmacological and pharmacological options.
• Prompt: How would you address her concerns about sexual dysfunction?

Q3. How would you approach the topic of potential domestic violence with Jane?

• Prompt: What strategies would you use to ensure Jane feels safe and supported?
• Prompt: How would you document any disclosures in a sensitive and confidential manner?

Q4. What are your considerations for follow-up and further care?

• Prompt: Discuss how you would involve other healthcare professionals or services.
• Prompt: What safety planning or referral options might be necessary?

Q5. What steps would you take if Jane does not disclose any domestic violence but you remain concerned?

• Prompt: Consider the use of screening tools, patient education, and ongoing monitoring.
• Prompt: How would you continue to provide care while maintaining patient trust and safety?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the main differential diagnoses to consider for Jane’s symptoms?

The main differential diagnoses for Jane’s symptoms should include both menopausal symptoms and other potential causes that might explain her presentation:

1. Menopausal symptoms:
   • Hot flushes, night sweats, mood swings, and low libido are classic signs of menopause. Elevated Follicle Stimulating Hormone (FSH) supports this diagnosis.
   • Genitourinary syndrome of menopause (GSM) should be considered, given the symptoms of painful intercourse, vaginal dryness, and sexual dysfunction.
2. Psychological causes:
   • Depression or anxiety disorder could exacerbate her menopausal symptoms, especially considering her history of anxiety and depression.
   • Possible adjustment disorder due to relationship stress or life changes (e.g., transitioning to part-time work).
3. Sexual dysfunction due to relationship dynamics:
   • Sexual dysfunction could result from psychological stress, a side effect of menopause, or underlying issues such as domestic violence (DV). Given Jane’s symptoms and the bruises observed, DV should be carefully considered.
4. Domestic violence:
   • The physical signs (bruises) combined with her anxiety and avoidance behavior strongly suggest DV. This could contribute to her psychological symptoms and sexual problems. A careful, non-judgmental exploration of these aspects is warranted.
5. Other potential medical causes:
   • Consider endocrine disorders (e.g., thyroid dysfunction, hyperprolactinemia) or systemic conditions (e.g., anemia, chronic fatigue syndrome) that may mimic or exacerbate menopausal symptoms.

Key considerations:

• Engage Jane in a supportive discussion about her symptoms, carefully addressing both menopausal and non-menopausal factors.
• Validate her symptoms and explore potential DV signs sensitively.
• Use screening tools for DV (such as HITS or HARK questionnaires) while ensuring her safety and confidentiality.

Q2: What initial management strategies would you suggest for Jane’s menopausal symptoms and sexual dysfunction?

Initial management should address both Jane’s menopausal symptoms and her sexual dysfunction, ensuring a patient-centered approach:

1. Menopausal symptoms management:
   • Lifestyle modifications: Encourage regular exercise, a balanced diet, adequate sleep, and avoiding triggers like hot drinks, caffeine, and alcohol.
   • Non-hormonal options: Suggest cognitive behavioral therapy (CBT) or mindfulness techniques for mood swings and hot flushes.
   • Hormonal options: Consider hormone replacement therapy (HRT) after discussing benefits, risks, and contraindications, especially given her history of mood disorders.
2. Management of sexual dysfunction:
   • Lubricants and moisturizers: Recommend vaginal lubricants or moisturizers to alleviate symptoms of vaginal dryness.
   • Pelvic floor exercises: Encourage pelvic floor muscle training if appropriate.
   • Referral to specialists: Consider referral to a sexual health specialist or psychologist if psychological factors or DV are suspected.
3. Addressing potential domestic violence:
   • Gently explore Jane’s safety at home, ensuring a private and confidential environment for discussion.
   • Provide information on local support services (e.g., helplines, women’s shelters) and consider referral to a social worker.
   • If Jane denies DV but you remain concerned, document carefully and plan regular follow-ups.
4. Follow-up and reassessment:
   • Schedule a follow-up appointment to reassess symptoms and management efficacy.
   • Monitor for adverse effects of HRT or any progression in her psychological symptoms.

Q3: How would you approach the topic of potential domestic violence with Jane?

To approach the topic of potential domestic violence (DV) with Jane:

1. Create a safe and private environment:
   • Ensure Jane feels comfortable and secure. Confirm that her partner is not present or within hearing range.
   • Use a calm, non-judgmental, and empathetic tone throughout the discussion.
2. Use gentle, open-ended questions:
   • Start with general questions: “How are things at home?” or “Do you feel safe in your relationship?”
   • If Jane shows signs of distress or avoids the question, reassure her that the discussion is confidential and only aimed at supporting her.
3. Offer validation and support:
   • Acknowledge her courage: “It can be difficult to talk about these things, but your safety is very important.”
   • Provide reassurance: “You don’t have to make any decisions right now, but I want you to know that I’m here to support you.”
4. Provide information on support services:
   • Offer details about local DV resources (e.g., helplines, women’s shelters, counselling services).
   • Emphasize that she is not alone and that help is available.
5. Document the discussion sensitively and accurately:
   • Ensure documentation is objective, factual, and does not compromise Jane’s safety.
   • Use coded language or euphemisms if Jane is concerned about her records being accessed by her partner.

Q4: What are your considerations for follow-up and further care?

Key considerations for Jane’s follow-up and further care:

1. Schedule regular follow-up appointments:
   • To review her menopausal symptoms, psychological health, and any signs of domestic violence (DV) if disclosed.
   • Ensure appointments are spaced to provide continuity of care and trust-building.
2. Monitor response to management:
   • Assess the effectiveness of menopause management strategies, such as hormone replacement therapy (HRT), if initiated.
   • Regularly evaluate Jane’s mental health and adjust treatments for depression/anxiety as needed.
3. Implement safety planning:
   • If DV is suspected, discuss a safety plan including safe places, contacts for emergencies, and support resources.
   • Consider a referral to social services or a DV advocate for further risk assessment and planning.
4. Collaborate with a multidisciplinary team:
   • Involve a psychologist, social worker, or counselor to address psychological aspects or DV.
   • Consider consultation with a menopause specialist if symptoms persist despite initial management.
5. Referral to appropriate services:
   • If DV is confirmed or highly suspected, refer Jane to appropriate support services discreetly.
   • Ensure that any referrals respect Jane’s privacy and consent.

Q5: What steps would you take if Jane does not disclose any domestic violence but you remain concerned?

If Jane does not disclose DV but concerns remain:

1. Continue providing a supportive environment:
   • Reassure Jane that she can speak freely in future consultations if she wishes to discuss anything.
2. Use screening tools discreetly:
   • Utilize tools like HITS (Hurt, Insult, Threaten, Scream) questionnaire over multiple visits to assess for DV in a non-confrontational manner.
3. Educate Jane on available resources:
   • Offer general information about local DV resources during routine discussions on health and safety.
   • Provide written material discreetly, such as a safety card or flyer, during a follow-up.
4. Monitor over time:
   • Keep an eye out for ongoing or new signs of DV (e.g., new injuries, worsening anxiety).
   • Maintain a high index of suspicion while respecting Jane’s autonomy.
5. Document observations carefully:
   • Record objective findings and statements verbatim without subjective interpretation.
   • Ensure documentation does not place Jane at increased risk if read by others.

SUMMARY OF A COMPETENT ANSWER

• Acknowledges multiple differential diagnoses considering menopausal, psychological, and social factors.
• Appropriately manages menopausal symptoms using a patient-centered approach, including both hormonal and non-hormonal options.
• Sensitive approach to potential domestic violence using open-ended questions and validation.
• Establishes a clear follow-up plan that addresses safety, ongoing symptom management, and referral to appropriate services.
• Utilizes screening tools and documents findings objectively to maintain patient safety and confidentiality.

PITFALLS

• Failing to consider domestic violence as a potential contributing factor to Jane’s symptoms.
• Not providing a safe environment for discussion of sensitive issues.
• Overlooking non-pharmacological options in managing menopausal symptoms.
• Neglecting follow-up care or safety planning for patients at risk of DV.
• Inadequate documentation that might compromise patient safety or confidentiality.

REFERENCES

• RACGP Guidelines on Menopause Management
• RACGP White Book: Abuse and Violence
• Australian Menopause Society Guidelines

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

2.2 Comprehensive history-taking, including biopsychosocial aspects.
2.5 Elicit and synthesize relevant information.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulate appropriate differential diagnoses.
3.3 Demonstrate logical clinical reasoning.

4. Clinical Management and Therapeutic Reasoning

4.2 Develop comprehensive and patient-centred management plans.
4.4 Provide appropriate therapeutic interventions.
4.7 Monitor ongoing care and adjust management as needed.

5. Preventive and Population Health

5.1 Promote health and well-being through effective education.
5.3 Implement strategies for primary and secondary prevention.

6. Professionalism

6.1 Maintain ethical and professional behaviour.
6.3 Reflect on practice to improve quality of care.

7. General Practice Systems and Regulatory Requirements

7.2 Understand regulatory requirements.
7.3 Use effective referral processes and follow-up.

9. Managing Uncertainty

9.1 Manage uncertainty in clinical decision-making.
9.3 Apply a structured approach to managing undifferentiated symptoms.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identify patients at risk of significant illness.
10.2 Provide timely and appropriate interventions.

Competency at Fellowship Level

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