EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your assessment of John’s current condition?

• Prompt: What factors suggest he is at risk for an exacerbation?
• Prompt: What additional history would you elicit?

Q2. How would you optimise John’s COPD management?

• Prompt: Review his current medication adherence and discuss potential changes.
• Prompt: What non-pharmacological strategies should be considered?

Q3. How would you discuss smoking cessation with John?

• Prompt: What evidence-based strategies could be recommended?
• Prompt: How would you address his previous relapses?

Q4. What is the role of spirometry in COPD management, and when should it be repeated?

• Prompt: How do you interpret his last spirometry results?
• Prompt: When would referral to a respiratory specialist be indicated?

Q5. What preventive measures should be discussed with John?

• Prompt: What vaccinations should be offered?
• Prompt: What strategies can help reduce hospitalisation risk?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your assessment of John’s current condition?

John Taylor, a 68-year-old male with moderate to severe COPD, presents with worsening dyspnoea, increased sputum production, and frequent salbutamol use, suggestive of a potential COPD exacerbation. His history of poor inhaler adherence, frequent exacerbations, and ongoing smoking places him at high risk for disease progression and hospitalisation.

Key features supporting exacerbation:

• Increased breathlessness and wheezing
• Higher use of reliever inhaler with reduced effect
• Increased sputum production
• Mild tachypnoea and hypoxia (RR 24, SpO₂ 93%)
• Expiratory wheeze and reduced breath sounds
• FEV1 45% predicted, confirming moderate to severe COPD

Differential diagnoses to consider:

• Heart failure exacerbation (but no peripheral oedema or signs of fluid overload)
• Pneumonia (normal WCC and CRP makes bacterial infection less likely)
• Pulmonary embolism (unlikely with no acute pleuritic pain or haemoptysis)

Further history required:

• Assess functional status (e.g., Modified MRC Dyspnoea Scale)
• Medication adherence and inhaler technique
• Recent weight changes or systemic symptoms
• Smoking habits and readiness to quit
• Social supports and ability to self-manage exacerbations

Management should include optimising medication use, smoking cessation, and considering pulmonary rehabilitation.

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Q2: How would you optimise John’s COPD management?

A stepwise approach is required to optimise COPD control and reduce exacerbations.

1. Review current pharmacotherapy:

• Ensure adherence to inhaled therapy (Tiotropium + Seretide)
• Add a long-acting beta-agonist (LABA) + long-acting muscarinic antagonist (LAMA) combination if symptoms persist
• Consider short-term oral corticosteroids (e.g., prednisolone 30-40mg for 5 days) if this is an exacerbation
• Antibiotics (amoxicillin/clavulanate or doxycycline) ONLY if infection is suspected

2. Optimise inhaler technique and adherence:

• Demonstrate proper technique for DPI/MDI with a spacer
• Assess inhaler preference and affordability

3. Non-pharmacological interventions:

• Smoking cessation – pharmacotherapy + counselling
• Pulmonary rehabilitation referral
• Vaccinations (influenza, pneumococcal, COVID-19)
• Develop an exacerbation action plan

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Q3: How would you discuss smoking cessation with John?

John has severe COPD and ongoing smoking, making cessation a priority.

1. Assess readiness to quit (5 A’s approach):

• Ask about smoking habits
• Advise on risks/benefits
• Assess readiness to quit
• Assist with pharmacotherapy
• Arrange follow-up

2. Pharmacotherapy options:

• Nicotine replacement therapy (NRT) – patches + gum/inhaler
• Varenicline (Champix) – more effective but contraindicated in some psychiatric conditions
• Bupropion (Zyban) – alternative if varenicline is unsuitable

3. Behavioural support:

• Refer to Quitline
• Provide motivational counselling
• Follow up regularly for relapse prevention

John has relapsed multiple times, so support should be individualised and ongoing.

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Q4: What is the role of spirometry in COPD management, and when should it be repeated?

Spirometry confirms COPD severity and guides treatment.

Key interpretation of John’s spirometry:

• FEV1/FVC = 55% (post-bronchodilator) → consistent with COPD
• FEV1 = 45% predicted → severe airflow limitation

Indications for repeat spirometry:

• Every 1-2 years to assess progression
• When there is a clinical change (e.g., worsening dyspnoea)
• Before stepping up therapy
• If considering referral to a specialist

Referral to respiratory specialist:

• Frequent exacerbations despite optimal therapy
• Consideration for long-term oxygen therapy (SpO₂ <88%)
• Possible lung volume reduction surgery assessment

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Q5: What preventive measures should be discussed with John?

Preventive care reduces exacerbations and hospitalisations.

1. Vaccinations:

• Annual influenza vaccine
• Pneumococcal vaccine (23-valent) if not received
• COVID-19 vaccination and boosters

2. Smoking cessation (as discussed in Q3).

3. Pulmonary rehabilitation:

• Improves exercise capacity and reduces symptoms

4. Personalised COPD action plan:

• Recognising early exacerbation signs
• Self-adjusting inhaler use
• When to seek medical attention

5. Regular follow-up:

• 3-monthly reviews to assess symptoms, adherence, and functional status

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SUMMARY OF A COMPETENT ANSWER

• Recognises COPD exacerbation and assesses severity
• Considers differential diagnoses while focusing on COPD progression
• Optimises pharmacological and non-pharmacological treatment
• Implements smoking cessation strategies tailored to patient readiness
• Demonstrates knowledge of spirometry use and referral criteria
• Emphasises prevention with vaccinations, pulmonary rehab, and action planning

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PITFALLS

• Failure to identify COPD exacerbation – misattributing symptoms to other causes
• Overprescribing antibiotics when there is no clear bacterial infection
• Not addressing inhaler technique – leading to ineffective medication use
• Ignoring smoking cessation – missing an opportunity for disease modification
• Not considering pulmonary rehabilitation referral
• Lack of personalised exacerbation action plan

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REFERENCES

• COPD-X Guidelines
• RACGP – COPD diagnosis, management and the role of the GP
• National Asthma Council – Inhaler Device Use
• Lung Foundation Australia – Pulmonary Rehabilitation
• GP Exams – Chronic Obstructive Pulmonary Disease (COPD)

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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.
1.3 Uses appropriate communication strategies to address health literacy limitations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history and targeted examination.
2.3 Identifies risk factors contributing to disease progression.

3. Diagnosis, Decision-Making and Reasoning

3.1 Makes an accurate diagnosis based on clinical and investigation findings.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate pharmacological and non-pharmacological management.

5. Preventive and Population Health

5.1 Discusses smoking cessation and modifiable risk factors.

Competency at Fellowship Level

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