EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Daniel’s skin infection?

• Prompt: How do you differentiate between bacterial, viral, and fungal skin infections?
• Prompt: What are red flag signs that require urgent intervention?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors would you assess for worsening infection?
• Prompt: When would you consider ordering wound cultures or blood tests?

Q3. How would you explain the diagnosis and management to Daniel in a clear and reassuring way?

• Prompt: How would you explain the need for antibiotics and possible drainage?
• Prompt: What wound care advice would you provide?

Q4. Outline your management plan for Daniel’s infection.

• Prompt: What is the role of oral vs topical antibiotics?
• Prompt: When would you consider incision and drainage?

Q5. What preventive measures can be recommended to reduce the risk of future skin infections?

• Prompt: How do hygiene and workplace precautions play a role?
• Prompt: When should Daniel seek medical attention for similar issues in the future?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Daniel’s skin infection?

A structured differential diagnosis is essential to differentiate common vs serious causes of skin infection.

• Bacterial Infections (most likely):
  • Cellulitis: Deep dermal infection with redness, warmth, tenderness, and systemic symptoms if severe.
  • Abscess: Localised collection of pus, fluctuant, may require drainage.
  • Impetigo: Superficial skin infection, honey-coloured crusts (less likely due to presentation).
• Fungal Infections:
  • Tinea corporis: Red, scaly, well-demarcated lesion with central clearing.
  • Candidiasis: Often in moist areas, associated with immunosuppression.
• Viral Infections:
  • Herpes simplex/zoster: Vesicular rash, dermatomal if zoster.
• Other Causes (red flags):
  • Necrotising fasciitis: Rapidly spreading, severe pain, systemic symptoms, requires urgent intervention.
  • Deep vein thrombosis (DVT): Consider if unilateral limb swelling, warmth, and risk factors present.
  • Inflammatory conditions: Eczema herpeticum, contact dermatitis, or insect bite reaction.

A competent candidate prioritises bacterial infections, ensuring red flag conditions are excluded.

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Q2: What further history and investigations would be useful in this case?

• Targeted History:
  • Progression: Onset, speed of spread, worsening pain.
  • Systemic symptoms: Fever, malaise, nausea.
  • Recent skin trauma: Cuts, insect bites, or prior wounds.
  • Comorbidities: Diabetes, immunosuppression.
  • Occupational risks: Exposure to contaminated tools or materials.
• Investigations (if indicated):
  • Clinical diagnosis is usually sufficient, but consider:
    • Wound swab for culture if: recurrent infection, failure to respond to treatment, or suspicion of MRSA.
    • FBC, CRP if systemic symptoms or extensive cellulitis.
    • Blood cultures if febrile or signs of sepsis.
    • Ultrasound if deep abscess suspected.

A competent candidate tailors investigations based on history and severity, avoiding unnecessary tests.

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Q3: How would you explain the diagnosis and management to Daniel in a clear and reassuring way?

1. Acknowledge concerns:
   • “I understand that this infection is causing discomfort and concern.”
2. Explain the diagnosis:
   • “Based on the appearance of your skin, this is most likely a bacterial skin infection, specifically a small abscess or early cellulitis.”
3. Address treatment plan:
   • “We can treat this with antibiotics and proper wound care. If the infection worsens, we may need to drain the abscess.”
4. Reassure about prognosis:
   • “Most infections like this improve within a week with treatment.”
5. Safety netting:
   • “If you notice spreading redness, fever, worsening pain, or pus, seek medical help urgently.”

A competent candidate balances reassurance with clear explanations, ensuring patient engagement and adherence.

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Q4: Outline your management plan for Daniel’s infection.

1. Antibiotic Therapy:
   • Oral flucloxacillin (first-line for Staphylococcus and Streptococcus) for 5–7 days.
   • If penicillin allergy, use cephalexin or clindamycin.
   • Consider MRSA coverage (e.g., trimethoprim-sulfamethoxazole or doxycycline) if risk factors present.
2. Wound Care:
   • Incision and drainage if pus collection is confirmed.
   • Daily dressing changes and hygiene advice.
3. Pain Management:
   • Paracetamol ± ibuprofen for pain relief.
4. Monitoring and Follow-up:
   • Review in 48 hours to ensure improvement.
   • If worsening, escalate to IV antibiotics or surgical referral.

A competent candidate follows an evidence-based approach, ensuring appropriate antibiotic use and wound management.

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Q5: What preventive measures can be recommended to reduce the risk of future skin infections?

1. Hygiene and Skin Care:
   • Wash hands regularly and keep wounds clean.
   • Avoid sharing towels, razors, or contaminated tools.
2. Workplace Precautions:
   • Wear protective gloves at work to prevent injuries.
   • Clean and disinfect tools regularly.
3. Early Recognition and Management:
   • Seek medical advice early if wounds become red, swollen, or painful.
   • Promptly treat minor cuts with antiseptic.

A competent candidate emphasises preventive strategies, ensuring long-term patient education.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates between bacterial, viral, and fungal causes of skin infections.
• Identifies red flags for urgent intervention, including necrotising fasciitis.
• Uses a targeted history-taking approach, focusing on systemic symptoms and occupational risks.
• Orders appropriate investigations when clinically indicated.
• Explains the diagnosis in a reassuring and patient-centred manner.
• Implements an evidence-based management plan, including antibiotics, wound care, and pain management.
• Provides clear safety netting and follow-up instructions.
• Educates on preventive strategies, including hygiene and workplace precautions.

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PITFALLS

• Failing to recognise red flag conditions (e.g., necrotising fasciitis, systemic sepsis).
• Over-prescribing antibiotics without considering wound drainage.
• Not addressing occupational risk factors, missing an opportunity for prevention.
• Providing inadequate safety netting, leading to missed deterioration.
• Not considering MRSA in at-risk individuals, resulting in treatment failure.

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REFERENCES

• RACGP – RACGP Guidelines on Skin and Soft Tissue Infections
• GP Exams – Skin infection NOS

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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 and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements an appropriate management plan.
4.3 Provides patient-centered management.

5. Preventive and Population Health

5.1 Applies preventive care strategies relevant to the patient’s condition.

Competency at Fellowship Level

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