CCE-CBD-078

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis and how would you confirm the diagnosis of rheumatoid arthritis?

Answer:

The primary diagnosis for Margaret is Rheumatoid Arthritis (RA). The differential diagnoses to consider include:

• Osteoarthritis (OA): Generally affects weight-bearing joints, with less pronounced inflammatory signs. Morning stiffness is usually less than 30 minutes.
• Psoriatic Arthritis: Often asymmetric and associated with psoriatic skin lesions, nail pitting.
• Polymyalgia Rheumatica (PMR): Common in people >50 years but typically involves proximal muscles rather than peripheral joints.
• Systemic Lupus Erythematosus (SLE): Can have joint involvement, but usually accompanied by systemic features and positive ANA.

Confirming RA diagnosis:

• History: Chronic, symmetrical joint pain and stiffness involving small joints (MCP, PIP). Morning stiffness >60 minutes is classic for RA.
• Examination findings: Tender, swollen MCP and PIP joints, reduced grip strength, and symmetrical involvement support RA.
• Investigations:
  • Serology: Positive Rheumatoid Factor (RF) and Anti-Cyclic Citrullinated Peptide (Anti-CCP) antibodies are highly specific.
  • Inflammatory markers: Elevated ESR and CRP indicate systemic inflammation.
  • X-ray findings: Joint space narrowing, erosions confirm chronicity and joint damage.

Based on ACR/EULAR 2010 criteria, she scores highly on joint involvement, serology, and symptom duration, supporting an RA diagnosis.

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Q2: What are your immediate management priorities for Margaret?

Answer:

The immediate priorities are to relieve symptoms, control inflammation, and prevent joint damage:

• Education and explanation of the condition, treatment goals, and the importance of early treatment.
• Non-pharmacological management:
  • Encourage joint protection strategies, ergonomic aids.
  • Refer to physiotherapy and occupational therapy for exercise, splinting, and functional support.
• Pharmacological management:
  • Start DMARDs, usually Methotrexate, as the first-line treatment (after baseline bloods, LFTs, and FBC).
  • Consider short-term corticosteroids (e.g., prednisolone) for symptom control.
  • Continue NSAIDs cautiously for pain, mindful of GI/renal risks.
• Referral: To a rheumatologist. If remote, use telehealth consultations.
• Care planning: Chronic disease management plan (GPMP/TCA).
• Vaccinations: Update pneumococcal and influenza vaccines prior to immunosuppression.

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Q3: How would you explain the role of DMARDs and their monitoring requirements to Margaret?

Answer:

Explain DMARDs as disease-modifying medications that slow disease progression and prevent joint damage:

• Methotrexate is commonly used, starting at 10-15 mg weekly, with folic acid supplementation.
• It may take 6-12 weeks for maximal effect.
• Benefits: Slows disease progression, reduces joint destruction.
• Risks: Liver toxicity, bone marrow suppression, pneumonitis.
• Monitoring:
  • Baseline bloods: FBC, LFT, renal function, chest X-ray.
  • Regular monitoring: 2-4 weekly initially, then 8-12 weekly once stable.
• Contraception advice if pre-menopausal (not applicable here).
• Reinforce adherence and explain the importance of follow-up.

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Q4: What preventive health measures are important in managing Margaret’s condition?

Answer:

• Immunisations: Pneumococcal, influenza, and COVID-19 boosters. Consider shingles vaccine before starting DMARDs.
• Bone health: She has osteopenia; ensure adequate calcium and vitamin D, and consider a DEXA scan update. Bisphosphonates may be considered if corticosteroids are used long-term.
• Cardiovascular risk: RA increases CVD risk. Manage BP, lipids, encourage exercise.
• Smoking cessation: Not applicable here.
• Weight management and encourage regular physical activity to maintain joint function.
• Cancer screening: Ensure up-to-date breast, cervical, and bowel screening.

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Q5: How would you address Margaret’s concerns about living in a rural area with limited access to specialist care?

Answer:

• Telehealth rheumatology services to provide timely specialist input.
• Coordinate local allied health services: physiotherapist, dietitian, and psychologist (if needed).
• Implement a GP Management Plan (GPMP) and Team Care Arrangement (TCA) for Medicare-funded allied health access.
• Ensure continuity of care with regular GP reviews and monitoring blood tests locally.
• Discuss community support services, Arthritis Australia, and rural health support programs.
• Empower self-management with education and reliable resources.

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SUMMARY OF A COMPETENT ANSWER

• Demonstrates accurate diagnosis based on clinical criteria and investigations.
• Outlines a comprehensive management plan, addressing both pharmacological and non-pharmacological strategies.
• Provides clear education on DMARDs and their monitoring.
• Emphasises preventive health, including immunisation, bone health, and CVD risk.
• Addresses rural health challenges, ensuring access to care through telehealth and local services.

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PITFALLS

• Failing to recognise the urgency of early DMARD initiation.
• Neglecting to arrange appropriate monitoring for DMARD therapy.
• Ignoring preventive health priorities such as immunisation and bone health.
• Inadequate consideration of rural health barriers and care coordination.
• Not explaining the progressive nature of RA and the importance of adherence.

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REFERENCES

• RACGP Guidelines
• Australian Rheumatology Association
• ACR/EULAR 2010 RA Classification Criteria

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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.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits an appropriate history informed by the patient’s context.
2.2 Performs an appropriate physical examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Selects appropriate investigations.
3.2 Demonstrates diagnostic reasoning with consideration of differentials.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan with appropriate treatments and referrals.
4.2 Explains therapeutic options and engages in shared decision-making.

5. Preventive and Population Health

5.1 Provides advice on preventive activities.

6. Professionalism

6.1 Demonstrates ethical practice and professional responsibility.

7. General Practice Systems and Regulatory Requirements

7.1 Uses appropriate systems to facilitate continuity of care.

9. Managing Uncertainty

9.1 Recognises and manages clinical uncertainty.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potentially serious conditions requiring further intervention.

12. Rural Health Context (RH)

RH1.1 Considers access to specialist care and local resources.

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Competency at Fellowship Level

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