EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Michael’s cough?

• Prompt: Can you provide a structured approach (e.g., acute, subacute, chronic)?
• Prompt: How does his smoking history influence your differentials?

Q2. What further history would you elicit to narrow down the diagnosis?

• Prompt: What red flag symptoms would you specifically ask about?
• Prompt: How would you differentiate between asthma, COPD, and reflux-related cough?

Q3. What investigations would you order and why?

• Prompt: What is the role of spirometry in this case?
• Prompt: Would you consider imaging? When and why?

Q4. Outline your management plan for Michael’s cough.

• Prompt: How would you address his smoking history?
• Prompt: What pharmacological and non-pharmacological treatments would you recommend?

Q5. What are the follow-up and safety-netting considerations?

• Prompt: When should Michael return for review?
• Prompt: What red flags should he watch for that would require urgent reassessment?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

---

Q1: What are your differential diagnoses for Michael’s cough?

• A competent candidate should provide a structured list of differential diagnoses for chronic cough (lasting >4 weeks), categorised into common causes:
  • Upper airway causes: Postnasal drip (upper airway cough syndrome), allergic rhinitis, chronic sinusitis.
  • Lower respiratory causes: Chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis.
  • Infectious causes: Pertussis, atypical pneumonia (Mycoplasma, Chlamydia), tuberculosis.
  • Gastrointestinal causes: Gastro-oesophageal reflux disease (GORD)-related cough.
  • Cardiac causes: Congestive heart failure.
  • Neoplastic causes: Lung cancer, given his smoking history and family history.
  • Environmental causes: Occupational exposure to dust/chemicals.
• A provisional diagnosis of COPD should be strongly considered based on the history of chronic cough, smoking, wheeze, and exertional dyspnoea.
• Red flag symptoms requiring further investigation: Haemoptysis, weight loss, worsening dyspnoea.

---

Q2: What further history would you elicit to narrow down the diagnosis?

• Clarify cough characteristics: Duration, timing, triggers, associated symptoms (wheeze, dyspnoea, chest pain, sputum production).
• Smoking history: Pack-years, previous quit attempts, willingness to stop.
• Exposure history: Occupational (dust, chemicals, asbestos), home environment (mould, pets).
• Red flag symptoms: Unintentional weight loss, night sweats, fever, haemoptysis.
• Previous respiratory history: Asthma, childhood infections, recurrent bronchitis.
• Gastrointestinal symptoms: Heartburn, regurgitation, chronic throat clearing (GORD-related cough).
• Medication review: ACE inhibitors, which may cause chronic cough.

---

Q3: What investigations would you order and why?

• Basic tests:
  • Chest X-ray (exclude malignancy, pneumonia, bronchiectasis).
  • Spirometry with bronchodilator response (differentiate COPD vs asthma).
  • Full blood count (infection, eosinophilia for asthma).
• Targeted investigations if indicated:
  • Sputum MCS and AFB if chronic infection suspected.
  • High-resolution CT if bronchiectasis or malignancy suspected.
  • 24-hour pH monitoring if GORD is suspected as a cause.

---

Q4: Outline your management plan for Michael’s cough.

• Smoking cessation: Essential for improving symptoms and reducing COPD progression. Offer nicotine replacement therapy (NRT) and referral to Quitline.
• Pharmacological management:
  • If COPD is diagnosed: Start long-acting bronchodilator (LAMA or LABA) based on severity.
  • If asthma is suspected: Consider inhaled corticosteroid (ICS)/LABA combination.
  • Manage postnasal drip with intranasal corticosteroids if allergic rhinitis is suspected.
  • If GORD is contributing: Proton pump inhibitor (PPI) trial.
• Vaccinations: Offer influenza and pneumococcal vaccines.
• Follow-up: Review response to treatment in 2-4 weeks, safety-net for worsening symptoms.

---

Q5: What are the follow-up and safety-netting considerations?

• Monitor symptom progression: Review response to treatment and ensure improvement.
• Refer if red flags develop: Persistent/worsening symptoms, haemoptysis, weight loss, significant airflow limitation on spirometry.
• Encourage smoking cessation follow-up: Regular review and support for quitting.
• Long-term management plan for COPD (if confirmed): Spirometry monitoring, pulmonary rehabilitation, escalation of therapy as needed.

---

SUMMARY OF A COMPETENT ANSWER

• Uses a structured approach to differential diagnoses, including upper/lower airway, gastrointestinal, cardiac, and malignancy causes.
• Identifies COPD as a likely diagnosis while considering other differentials.
• Demonstrates red flag awareness, including weight loss, haemoptysis, and persistent worsening symptoms.
• Orders appropriate investigations based on clinical suspicion (spirometry, CXR, blood tests).
• Provides a patient-centred management plan, including smoking cessation, pharmacotherapy, and follow-up.
• Implements safety-netting strategies to monitor for complications and escalation.

---

PITFALLS

• Failing to consider serious causes such as lung cancer or bronchiectasis in a smoker with a chronic cough.
• Overlooking smoking cessation as a key component of management.
• Not ordering spirometry to differentiate COPD from asthma.
• Failing to safety-net for worsening symptoms or red flag signs.
• Over-prescribing antibiotics without clear evidence of infection.

---

REFERENCES

• RACGP Guidelines on Chronic Cough
• National Asthma Council Australia on Cough and Airway Hyperreactivity
• Lung Foundation Australia on Smoking Cessation and Chronic Cough
• NIH Guidelines on Cough Management in Primary Care

---

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.
1.3 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic and hypothesis-driven history to differentiate causes of cough.
2.2 Performs relevant physical examination to support or exclude differential diagnoses.
2.3 Orders and interprets appropriate investigations based on the clinical presentation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies red flag symptoms requiring urgent intervention.
3.2 Differentiates between self-limiting and serious causes of cough (e.g., acute infection vs chronic conditions).

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan based on probable diagnosis.
4.2 Provides evidence-based treatment and symptomatic relief options.

5. Preventive and Population Health

5.1 Discusses smoking cessation and vaccination as preventive strategies.
5.2 Provides education on respiratory health and when to seek medical review.

6. Professionalism

6.1 Maintains a patient-centred approach while respecting the patient’s health beliefs.

7. General Practice Systems and Regulatory Requirements

7.1 Documents clinical findings and management appropriately in medical records.

8. Procedural Skills

8.1 Demonstrates appropriate use of respiratory examination techniques.

9. Managing Uncertainty

9.1 Provides a safety-netting plan for undifferentiated cough presentations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of pneumonia or serious pathology requiring escalation.

Competency at Fellowship Level

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