EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess James’ fatigue and determine the most likely causes?

• Prompt: What key elements of the history and examination are important?
• Prompt: What differentials should be considered?

Q2. What investigations would you order, and why?

• Prompt: When should additional blood tests or imaging be considered?
• Prompt: When is a sleep study warranted?

Q3. How would you approach the management of James’ fatigue?

• Prompt: What lifestyle modifications should be prioritised?
• Prompt: When should pharmacological management be considered?

Q4. How would you address James’ concerns about an undiagnosed medical condition?

• Prompt: How would you explain the role of stress and lifestyle factors in fatigue?
• Prompt: What strategies can help reassure and empower him?

Q5. What long-term preventive strategies would you recommend?

• Prompt: How can he optimise sleep hygiene?
• Prompt: What role do diet, exercise, and stress management play in fatigue prevention?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess James’ fatigue and determine the most likely causes?

James presents with persistent fatigue for six months. A structured approach includes history, examination, and differential diagnosis.

1. History

• Fatigue pattern – sudden vs gradual onset, fluctuation through the day
• Sleep quality – duration, interruptions, snoring, possible sleep apnoea
• Mental health – stress, mood changes, anxiety, burnout symptoms
• Dietary factors – caffeine, alcohol, meal patterns
• Medical history – medication side effects, chronic illnesses

2. Differential Diagnosis

• Lifestyle factors – poor sleep hygiene, high caffeine/alcohol intake
• Psychological causes – stress, burnout, depression, anxiety
• Medical causes:
  • Sleep apnoea – fatigue, unrefreshed sleep
  • Hypothyroidism – ruled out by normal TSH
  • Iron deficiency anaemia – unlikely as ferritin is normal

James’ fatigue is most likely multifactorial, with a strong contribution from lifestyle and stress-related factors.

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Q2: What investigations would you order, and why?

James has no red flags, and initial blood tests are normal. Investigations should be targeted to rule out key differentials.

1. Already performed and normal

• FBC, ferritin, thyroid function, fasting glucose, liver function

2. Further investigations (if warranted)

• Sleep study – if symptoms suggest sleep apnoea (snoring, witnessed apnoeas)
• Mental health screening – PHQ-9 (depression), GAD-7 (anxiety)

A sleep study is reasonable given his unrefreshing sleep and work-related fatigue.

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Q3: How would you approach the management of James’ fatigue?

1. Lifestyle Modifications (First-Line)

• Sleep hygiene – fixed bedtime, no screens before bed
• Reduce caffeine/alcohol – limit caffeine intake, alcohol before sleep
• Increase physical activity – regular exercise improves energy levels

2. Psychosocial Support

• Stress management techniques – mindfulness, structured breaks
• Referral to psychologist if burnout or anxiety is suspected

3. Medical Management

• If sleep study confirms sleep apnoea → CPAP referral
• Follow-up in 4-6 weeks to assess improvement

A holistic approach addressing lifestyle, sleep, and stress is key.

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Q4: How would you address James’ concerns about an undiagnosed medical condition?

1. Explain the Findings

• Blood tests and examination are reassuring
• No evidence of serious medical conditions

2. Address the Role of Lifestyle and Stress

• Poor sleep, stress, and caffeine are significant contributors
• Fatigue is often multifactorial, requiring a combination of changes

3. Reassurance and Follow-Up

• Set a review in 4-6 weeks to assess progress
• Adjust management if symptoms persist

Providing clear explanations and a structured plan alleviates anxiety.

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Q5: What long-term preventive strategies would you recommend?

1. Optimising Sleep Hygiene

• Fixed bedtime and wake-up time
• Limit screen time before bed

2. Diet and Exercise

• Reduce caffeine and alcohol intake
• Regular physical activity to boost energy and mood

3. Stress and Mental Health Management

• Work-life balance strategies
• Mindfulness or relaxation techniques

Long-term healthy habits prevent recurrent fatigue and improve well-being.

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SUMMARY OF A COMPETENT ANSWER

• Identifies lifestyle and stress-related contributors to fatigue
• Orders appropriate investigations while avoiding unnecessary tests
• Provides lifestyle and sleep hygiene modifications
• Addresses patient concerns with clear explanations
• Implements preventive strategies for long-term fatigue management

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PITFALLS

• Failing to assess psychological contributors such as stress and burnout
• Over-investigating when lifestyle factors are the primary cause
• Not considering sleep apnoea as a potential contributor
• Providing reassurance without a structured follow-up plan
• Neglecting preventive strategies like exercise and diet modification

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REFERENCES

• RACGP Guidelines on Chronic Fatigue
• Australian Thyroid Foundation on Fatigue and Thyroid Disorders
• Jean Hailes for Women’s Health on Fatigue and Perimenopause
• Therapeutic Guidelines on Fatigue and Anaemia

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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 Uses a structured approach to explore fatigue causes.
1.3 Explains diagnostic and management plans clearly to the patient.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough fatigue history, including lifestyle and psychological factors.
2.3 Identifies red flags that warrant urgent investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common and serious causes of fatigue.
3.3 Uses clinical reasoning to guide investigations and avoid unnecessary tests.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan based on likely causes.
4.4 Addresses lifestyle factors contributing to fatigue.

5. Preventive and Population Health

5.1 Provides guidance on sleep hygiene, nutrition, and mental well-being.

6. Professionalism

6.2 Provides a patient-centred and empathetic approach to fatigue management.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate investigations and ensures follow-up of abnormal results.

8. Procedural Skills

8.2 Conducts relevant bedside tests (e.g., cardiovascular, neurological, mental health assessments).

9. Managing Uncertainty

9.1 Recognises when to initiate empirical management versus awaiting test results.

10. Identifying and Managing the Patient with Significant Illness

10.2 Identifies when fatigue is a symptom of serious underlying pathology.

Competency at Fellowship Level

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