EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Sarah’s allergic rhinitis and confirm the diagnosis?

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

Q2. What is your initial management plan for Sarah?

• Prompt: What pharmacological treatments are first-line?
• Prompt: What non-pharmacological measures should be discussed?

Q3. When would you consider referral for allergy testing or specialist review?

• Prompt: What are the indications for allergy testing?
• Prompt: When should an ENT specialist be involved?

Q4. What lifestyle and environmental modifications can help reduce Sarah’s symptoms?

• Prompt: How can allergen avoidance be implemented at home and work?
• Prompt: What role does nasal irrigation play in allergic rhinitis management?

Q5. What long-term strategies can help prevent recurrence and improve quality of life?

• Prompt: What is the role of immunotherapy in allergic rhinitis?
• Prompt: How should Sarah monitor and adjust her treatment over time?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Sarah’s allergic rhinitis and confirm the diagnosis?

Sarah presents with recurrent nasal congestion, sneezing, and itchy eyes that are worse in spring and indoors. A structured approach includes history, examination, and differential diagnosis.

1. History

• Onset and duration – seasonal vs perennial symptoms
• Triggers – dust, pollen, pets, cold air, perfume
• Pattern – worse in the morning, improves outdoors
• Associated symptoms – nasal congestion, sneezing, itchy eyes, postnasal drip
• Impact on daily life – sleep disturbances, work performance

2. Differential Diagnosis

• Allergic rhinitis – seasonal, sneezing, clear rhinorrhoea, itchy eyes
• Non-allergic rhinitis – triggered by weather, perfume, no itching
• Chronic sinusitis – nasal congestion, facial pain, purulent discharge
• Nasal polyps – persistent congestion, anosmia

3. Physical Examination Findings

• Pale, swollen nasal mucosa, clear rhinorrhoea → allergic rhinitis
• No nasal polyps or septal deviation → rules out structural cause
• Oropharynx normal → excludes postnasal drip from infection

Sarah’s history and examination are consistent with allergic rhinitis.

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Q2: What is your initial management plan for Sarah?

1. First-Line Pharmacological Treatment

• Intranasal corticosteroids (e.g., fluticasone, budesonide) – most effective
• Second-generation oral antihistamines (e.g., loratadine, fexofenadine) – for breakthrough symptoms

2. Non-Pharmacological Measures

• Saline nasal irrigation – washes out allergens
• Avoidance strategies – minimise exposure to pollen and dust

3. Follow-Up Plan

• Review in 4 weeks to assess symptom control
• Adjust treatment based on response

Sarah should see improvement with a combination of pharmacological and lifestyle strategies.

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Q3: When would you consider referral for allergy testing or specialist review?

1. Indications for Allergy Testing (Skin Prick or IgE Testing)

• Unclear triggers or severe symptoms despite treatment
• Considering immunotherapy

2. When to Refer to an ENT Specialist

• Suspected nasal polyps, chronic sinusitis, or persistent congestion despite treatment

Referral is needed for refractory symptoms or suspected structural pathology.

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Q4: What lifestyle and environmental modifications can help reduce Sarah’s symptoms?

1. Reducing Allergen Exposure

• Dust-proof covers on pillows and mattresses
• Keep windows closed during peak pollen season
• Use HEPA air filters in the home

2. Symptom Management Strategies

• Daily saline nasal irrigation
• Showering after outdoor exposure to remove pollen

Environmental modifications help minimise allergen exposure.

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Q5: What long-term strategies can help prevent recurrence and improve quality of life?

1. Ongoing Pharmacotherapy

• Regular intranasal corticosteroids – most effective for long-term control

2. Immunotherapy (Allergy Desensitisation)

• Considered if symptoms persist despite treatment
• Requires allergy testing to confirm specific triggers

3. Patient Education and Monitoring

• Adjust treatment seasonally based on symptom patterns

Sarah benefits from a long-term plan incorporating medication, avoidance, and potential immunotherapy.

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SUMMARY OF A COMPETENT ANSWER

• Takes a thorough allergy history and differentiates allergic rhinitis from other causes
• Provides first-line treatment with intranasal corticosteroids and antihistamines
• Advises on allergen avoidance and environmental control
• Recognises when allergy testing or ENT referral is needed
• Discusses long-term management including immunotherapy for refractory cases

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PITFALLS

• Misdiagnosing allergic rhinitis as sinusitis and overprescribing antibiotics
• Failing to initiate intranasal corticosteroids as first-line treatment
• Overlooking allergen avoidance strategies
• Not recognising when specialist referral is needed
• Neglecting to discuss the role of immunotherapy for severe cases

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REFERENCES

• RACGP Guidelines on Allergic Rhinitis Management
• National Asthma Council Australia on Allergic Rhinitis and Asthma
• Therapeutic Guidelines on Allergic Rhinitis Treatment
• ASCIA (Australasian Society of Clinical Immunology and Allergy) Guidelines

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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 clear and empathetic communication when discussing allergic rhinitis.
1.3 Provides structured education on triggers, treatment options, and preventive strategies.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough allergy history, including triggers and seasonal patterns.
2.3 Identifies red flags that suggest an alternative or more serious condition.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates allergic rhinitis from other causes of nasal congestion.
3.3 Determines when allergy testing or referral to an allergist is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based treatment plan tailored to symptom severity.
4.4 Advises on pharmacological and non-pharmacological management.

5. Preventive and Population Health

5.1 Provides education on allergen avoidance and environmental control strategies.

6. Professionalism

6.2 Ensures patient-centred care and addresses quality-of-life concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Documents history, treatment, and follow-up plan appropriately.

8. Procedural Skills

8.2 Performs a focused ENT examination including nasal inspection.

9. Managing Uncertainty

9.1 Recognises when empirical treatment is appropriate vs when further testing is needed.

10. Identifying and Managing the Patient with Significant Illness

10.2 Differentiates allergic rhinitis from more serious nasal conditions (e.g., nasal polyps, sinusitis).

Competency at Fellowship Level

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