EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Michael’s presentation?

• Prompt: How do you differentiate between substance-induced and primary mental health disorders?
• Prompt: What red flags suggest an acute psychiatric or medical emergency?

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

• Prompt: What risk factors need further exploration?
• Prompt: What screening tests would you consider?

Q3. How would you engage Michael in a conversation about his drug use and readiness for change?

• Prompt: How do you use motivational interviewing to assess his goals?
• Prompt: How do you provide harm minimisation advice?

Q4. Outline your initial management plan for Michael.

• Prompt: What pharmacological and non-pharmacological interventions would be appropriate?
• Prompt: When would you refer him for specialist addiction or mental health services?

Q5. What preventive health strategies should be implemented for Michael?

• Prompt: What vaccinations and screening tests are relevant?
• Prompt: How can you address his smoking and alcohol use?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Michael’s presentation?

A structured approach is required to differentiate between substance-induced symptoms and primary mental health conditions.

• Substance-Induced Disorders (Most Likely):
  • Methamphetamine intoxication – Agitation, paranoia, tachycardia, hypervigilance, pressured speech.
  • Methamphetamine withdrawal – Fatigue, depression, irritability, anhedonia, cravings.
  • Substance-induced psychosis – Paranoia, hallucinations, disorganised thinking, often resolves after drug clearance.
• Primary Psychiatric Disorders (Must Consider):
  • Generalised Anxiety Disorder (GAD) – Pre-existing in Michael, can be worsened by stimulant use.
  • Major Depressive Disorder – If symptoms persist beyond withdrawal.
  • Bipolar Disorder – If mood instability and impulsivity predate substance use.
  • Schizophrenia – Persistent delusions or hallucinations despite abstinence.
• Medical Causes (Red Flags):
  • Cardiac arrhythmias or hypertension – Methamphetamine-related cardiotoxicity.
  • Hepatitis B or C – High-risk drug use.
  • Neurological conditions – If persistent cognitive symptoms post-abstinence.

A competent candidate prioritises substance-related effects while assessing for co-existing psychiatric or medical conditions.

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

• Further History:
  • Pattern of drug use: Frequency, amount, route, attempts to quit, cravings.
  • Withdrawal symptoms: Severity, past withdrawal experiences, overdose history.
  • Mental health history: Pre-existing depression, anxiety, suicidal thoughts.
  • Social and legal concerns: Housing, employment, legal issues, support systems.
• Investigations:
  • Urine drug screen – Confirms recent methamphetamine and benzodiazepine use.
  • Liver function tests (LFTs) – Assess for alcohol or drug-related liver damage.
  • Hepatitis B, C, HIV screening – Due to past IV drug use.
  • ECG – If hypertensive, tachycardic, or at risk of arrhythmias.

A competent candidate tailors investigations to assess acute and long-term risks.

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Q3: How would you engage Michael in a conversation about his drug use and readiness for change?

1. Build rapport and validate concerns:
   • “I appreciate you coming in today—it’s not easy to talk about drug use.”
2. Use motivational interviewing techniques:
   • Open-ended questions: “What concerns do you have about your methamphetamine use?”
   • Assess readiness: “On a scale of 1-10, how ready are you to make a change?”
   • Explore pros and cons: “What do you enjoy about using? What don’t you like?”
3. Harm minimisation approach:
   • Safer drug use: Avoid IV use, use clean needles, hydrate, eat well.
   • Recognising overdose signs: Chest pain, severe paranoia, confusion.
   • Link to needle exchange programs if applicable.
4. Discuss treatment options without pressure:
   • “If you decide to cut down, there are supports available, including medical and psychological help.”

A competent candidate avoids judgement, explores motivation, and promotes harm reduction.

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Q4: Outline your initial management plan for Michael.

1. Acute Symptom Management:
   • If agitated, consider short-term benzodiazepine (e.g., diazepam 2-5mg PRN).
   • If psychotic features, consider antipsychotic (e.g., olanzapine 2.5-5mg PRN).
   • Monitor for withdrawal symptoms, ensuring safety at home.
2. Referral and Support Services:
   • Drug and Alcohol Counselling – Link to local addiction services.
   • Mental Health Support – Consider psychologist or GP Mental Health Treatment Plan.
   • Peer support programs – Encourage Narcotics Anonymous or SMART Recovery.
3. Long-Term Management Plan:
   • Regular GP reviews – Monitor mental health, support change.
   • Consider pharmacotherapy – N-acetylcysteine (NAC) may help cravings.
   • Crisis planning – Identify relapse triggers and emergency support options.

A competent candidate provides a structured, multidisciplinary approach focusing on safety and support.

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Q5: What preventive health strategies should be implemented for Michael?

1. Vaccination and Screening:
   • Hepatitis B vaccine if not immune.
   • STI screening, including HIV, syphilis, chlamydia, gonorrhoea.
2. Lifestyle and General Health:
   • Smoking cessation support – NRT, varenicline, behavioural therapy.
   • Alcohol harm reduction – Encourage low-risk drinking strategies.
   • Nutrition and sleep hygiene – Essential for physical and mental recovery.
3. Regular Mental Health Check-Ins:
   • Screening for depression, anxiety, PTSD.
   • Crisis planning – Identify support services for relapse prevention.

A competent candidate integrates physical and mental health prevention strategies into long-term care.

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SUMMARY OF A COMPETENT ANSWER

• Recognises substance-induced vs primary psychiatric conditions, prioritising withdrawal and psychosis risk.
• Takes a structured history, covering drug use pattern, mental health, social risk factors.
• Orders targeted investigations, including urine drug screen, LFTs, hepatitis serology.
• Uses motivational interviewing, engaging without judgement while promoting harm minimisation.
• Implements an evidence-based management plan, with mental health support, addiction referrals, and medication if required.
• Integrates preventive care, including vaccination, STI screening, and lifestyle modifications.

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PITFALLS

• Being judgemental or dismissive, which reduces engagement in care.
• Failing to screen for medical complications, such as hepatitis C or cardiovascular risks.
• Not considering harm minimisation, missing an opportunity to reduce overdose and transmission risks.
• Neglecting long-term mental health support, leading to poor relapse prevention.
• Over-relying on pharmacotherapy, without addressing psychosocial interventions.

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REFERENCES

• RACGP –RACGP Alcohol and Other Drug (AOD) Guidelines
• GP Exams – Drug abuse

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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.

Competency at Fellowship Level

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