EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: What clinical features suggest bacterial versus viral tonsillitis?
• Prompt: What additional history would you ask to assess severity and complications?

Q2. How would you manage Emily’s condition?

• Prompt: When would you prescribe antibiotics?
• Prompt: What supportive care measures would you recommend?

Q3. How would you address the parent’s concerns about recurrent tonsillitis and possible tonsillectomy?

• Prompt: What are the criteria for ENT referral?
• Prompt: How would you counsel on non-surgical management?

Q4. When would you suspect complications such as peritonsillar abscess (quinsy), and how would you manage it?

• Prompt: What red flag symptoms suggest quinsy?
• Prompt: When would you escalate care?

Q5. What preventive measures should be discussed with Emily’s family?

• Prompt: How can recurrent tonsillitis be minimised?
• Prompt: What is the role of hand hygiene and infection control in schools?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Emily, a 9-year-old female, presents with fever, sore throat, and difficulty swallowing for three days. The absence of cough and rhinorrhoea increases the likelihood of bacterial tonsillitis. Examination findings show bilateral tonsillar enlargement with exudates, palatal petechiae, and tender anterior cervical lymphadenopathy, which are consistent with Group A Streptococcus (GAS) pharyngitis.

Assessment Based on Centor/McIsaac Criteria:

The modified Centor score (McIsaac score) helps differentiate between viral and bacterial pharyngitis:

• Tonsillar exudates (+1)
• Tender anterior cervical lymphadenopathy (+1)
• Fever >38°C (+1)
• Age 3-14 years (+1)
• No cough (+1)

With a score of 4/5, streptococcal infection is highly likely, justifying either empirical antibiotic treatment or throat swab confirmation.

Differential Diagnoses:

• Viral pharyngitis (EBV, adenovirus, influenza, COVID-19)
• Peritonsillar abscess (quinsy) – ruled out due to lack of unilateral swelling or uvular deviation
• Herpangina (Coxsackievirus) – unlikely due to lack of vesicular lesions

Additional history should explore hydration status, difficulty breathing, history of rheumatic fever, or recurrent tonsillitis.

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Q2: How would you manage Emily’s condition?

1. Symptomatic Treatment:

• Adequate hydration and soft diet
• Analgesia (paracetamol/ibuprofen) for pain and fever
• Saltwater gargles for comfort

2. Antibiotic Indications:

• If bacterial tonsillitis is suspected (Centor ≥3), penicillin V (first-line) for 10 days is recommended.
• Amoxicillin can be used for younger children due to better palatability.
• Avoid amoxicillin if EBV is suspected to prevent rash.
• Cephalexin or azithromycin for penicillin allergy.

3. Education and Follow-up:

• Discuss viral vs bacterial infections and why antibiotics may not always be needed.
• Reassess in 48-72 hours if worsening symptoms or poor oral intake.

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Q3: How would you address the parent’s concerns about recurrent tonsillitis and possible tonsillectomy?

Tonsillectomy Indications (RACGP/NICE guidelines):

Consider referral if:

• ≥7 episodes/year, ≥5 per year for 2 years, or ≥3 per year for 3 years
• Recurrent peritonsillar abscess (quinsy)
• Obstructive sleep apnoea
• Failure to thrive due to recurrent infections

Reassure the parent that most children outgrow recurrent tonsillitis by adolescence and that tonsillectomy is not always necessary. If recurrent infections significantly impact quality of life, ENT referral is appropriate.

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Q4: When would you suspect complications such as peritonsillar abscess (quinsy), and how would you manage it?

Red Flags for Quinsy:

• Unilateral tonsillar swelling
• Uvula deviation
• Severe throat pain with trismus (difficulty opening mouth)
• Muffled “hot potato” voice

Management:

• Immediate ENT referral for drainage
• IV antibiotics (benzylpenicillin or clindamycin if allergic)
• Analgesia and IV fluids if dehydrated
• Consider hospital admission if airway compromise is suspected

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Q5: What preventive measures should be discussed with Emily’s family?

1. Hygiene and Infection Control:

• Handwashing and avoiding sharing utensils
• Covering coughs/sneezes
• Staying home from school if febrile

2. Management of Recurrent Infections:

• Hydration and good oral hygiene
• Monitor symptoms and avoid unnecessary antibiotic use

3. Vaccination:

• Influenza and COVID-19 vaccines to reduce viral pharyngitis risk.

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SUMMARY OF A COMPETENT ANSWER

• Accurately differentiates bacterial vs viral tonsillitis using McIsaac criteria
• Applies appropriate antibiotic stewardship
• Effectively addresses parental concerns regarding tonsillectomy
• Recognises complications such as peritonsillar abscess
• Provides preventive advice on hygiene and infection control

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PITFALLS

• Prescribing antibiotics unnecessarily for viral infections
• Failing to assess for quinsy in a worsening sore throat
• Not addressing parental concerns about surgery
• Overlooking non-pharmacological symptomatic treatment

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REFERENCES

• RACGP – Clinical insights into appropriate choice of antimicrobials for acute respiratory tract infections
• Therapeutic Guidelines – Antibiotic – Sore Throat
• Australian Commission on Safety and Quality in Health Care – Antibiotic Stewardship
• GP Exams – Tonsillitis

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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 children and caregivers.
1.3 Uses appropriate language to explain diagnosis and management to parents.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a focused paediatric history and examination.
2.2 Differentiates between bacterial and viral tonsillitis using clinical criteria.

3. Diagnosis, Decision-Making and Reasoning

3.1 Makes an accurate diagnosis based on clinical presentation.
3.3 Appropriately uses clinical scoring tools (e.g., Centor or McIsaac criteria).

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based antibiotic therapy when indicated.
4.4 Discusses analgesia, hydration, and symptomatic relief measures.

5. Preventive and Population Health

5.1 Provides education on infection prevention and transmission.

6. Professionalism

6.2 Manages parental expectations regarding antibiotic use.

7. General Practice Systems and Regulatory Requirements

7.1 Prescribes appropriately based on current antibiotic stewardship guidelines.

8. Procedural Skills

8.2 Performs an oropharyngeal examination confidently.

9. Managing Uncertainty

9.1 Recognises when to refer for specialist ENT review (e.g., recurrent tonsillitis).

10. Identifying and Managing the Patient with Significant Illness

10.2 Identifies complications such as peritonsillar abscess.

Competency at Fellowship Level

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