EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you interpret these test results for John?

• Prompt: Explain the significance of each positive test.
• Prompt: What further tests or confirmatory steps are required?
• Prompt: What possible explanations exist for the positive HIV ELISA?

Q2. How would you counsel John regarding the implications of these results?

• Prompt: How would you address his concerns about HIV and syphilis?
• Prompt: What reassurance or follow-up would you provide?

Q3. What are the next steps in managing John’s case?

• Prompt: What additional investigations or referrals would be appropriate?
• Prompt: Does John require any immediate treatment or public health notification?

Q4. How would you communicate the need for follow-up and possible disease notification?

• Prompt: What are the ethical considerations in discussing infectious disease risks?
• Prompt: How would you explain the need for partner notification?

Q5. What preventive health advice would you provide to John for future travel and work-related exposures?

• Prompt: Discuss relevant vaccinations or travel precautions.
• Prompt: What advice on safer sex practices should be given?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you interpret these test results for John?

A structured approach to interpreting the test results should be taken:

1. HIV ELISA positive
   • ELISA is a screening test, and a positive result requires confirmatory testing with a Western blot or nucleic acid test (NAT).
   • Possible false positive due to cross-reactivity (e.g., recent viral infection, autoimmune disease).
   • Patient must be counselled appropriately regarding the uncertainty of the result.
2. Syphilis RPR 1:4, TPPA pending
   • A low RPR titre may indicate previous treated infection, latent syphilis, or biological false positivity.
   • The Treponema pallidum particle agglutination (TPPA) test will confirm whether the patient has true infection or a false positive.
3. Dengue IgM positive
   • Suggests recent or current infection.
   • IgM positivity without NS1 antigen or PCR confirmation could indicate cross-reactivity (e.g., prior flavivirus exposure or vaccination).
4. EBV & CMV IgG positive, IgM negative
   • Indicates past exposure, not an active infection.
5. Mildly elevated CRP & WCC
   • Non-specific findings, can occur with viral infections, recent immunological activation, or another inflammatory process.
6. Mild ALT elevation (45 U/L)
   • Could be due to viral infections (e.g., dengue, EBV, CMV) or lifestyle factors.
   • Requires monitoring but not immediately concerning.

Key Considerations

• Further tests: Western blot for HIV, TPPA for syphilis, Dengue NS1/PCR.
• Public health implications: Potential HIV and syphilis notification.
• Patient counselling: Avoid unnecessary alarm while awaiting confirmatory results.

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Q2: How would you counsel John regarding the implications of these results?

1. Acknowledging patient concerns
   • “I understand this is stressful. Some results need further confirmation, and false positives can occur.”
2. Explaining uncertain results
   • HIV ELISA positive does not mean confirmed HIV. Further tests are needed.
   • Syphilis low RPR titre may indicate a past or inactive infection.
   • Dengue IgM positivity could be due to past exposure or another virus.
3. Clear next steps
   • Confirmatory tests will be arranged.
   • No immediate treatment needed for most findings.
   • If syphilis or HIV is confirmed, appropriate treatment and support will be provided.
4. Reassurance and follow-up
   • “We will support you through this. Let’s schedule a follow-up appointment once we have the full picture.”

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Q3: What are the next steps in managing John’s case?

1. Confirmatory testing
   • HIV: Western blot or NAT.
   • Syphilis: TPPA.
   • Dengue: NS1 antigen or PCR if symptoms persist.
2. Contact tracing if necessary
   • If syphilis or HIV is confirmed, partner notification is required.
3. Follow-up plan
   • 1-week review to discuss confirmatory results.
   • Further specialist referral if needed.
4. Public health reporting
   • Notify appropriate authorities if syphilis or HIV is confirmed.

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Q4: How would you communicate the need for follow-up and possible disease notification?

1. Patient confidentiality
   • “Your results are confidential, but some infections require notification for public health reasons.”
2. Explaining legal obligations
   • “Certain infections, such as syphilis and HIV, must be reported to ensure appropriate public health measures.”
3. Partner notification
   • Encourage open discussions with recent partners.
   • Offer assistance with anonymous notification services.
4. Ongoing care
   • Ensure non-judgemental support.
   • Provide written information on infectious diseases.

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Q5: What preventive health advice would you provide to John for future travel and work-related exposures?

1. Vaccinations
   • Hepatitis B, Typhoid, Japanese Encephalitis, as appropriate.
2. Safe sex practices
   • Consistent condom use.
   • Regular sexual health screening.
3. Travel precautions
   • Use insect repellents to prevent mosquito-borne infections.
   • Avoid drinking untreated water in endemic areas.
4. General health advice
   • Maintain good hygiene.
   • Be aware of symptoms and seek medical attention if unwell after travel.

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SUMMARY OF A COMPETENT ANSWER

• Structured interpretation of test results with explanations of possible false positives.
• Clear patient-centred counselling, addressing anxiety and next steps.
• Practical management plan, including confirmatory tests, follow-up, and public health reporting.
• Ethical and legal discussion around disease notification and partner tracing.
• Comprehensive preventive advice, including vaccinations, travel safety, and sexual health.

PITFALLS

• Overinterpreting preliminary results without considering false positives.
• Failing to communicate uncertainty effectively, causing unnecessary distress.
• Not considering the need for confirmatory testing, particularly for HIV and syphilis.
• Neglecting the public health aspect, such as partner notification and mandatory reporting.
• Providing insufficient preventive health advice, particularly regarding travel and sexual health.

REFERENCES

• RACGP – RACGP Guidelines on Immunodeficiency & Recurrent Infections
• GP Exams – Microbiology/immunology test 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 with patients about test results.
1.2 Explains microbiology and immunology tests in lay terms.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history relevant to infectious disease exposure.
2.2 Interprets microbiological and serological test results.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies potential differential diagnoses based on test results.
3.2 Uses clinical reasoning to determine the significance of positive or negative microbiological findings.

4. Clinical Management and Therapeutic Reasoning

4.1 Plans appropriate follow-up based on test results.
4.2 Determines whether treatment or further testing is necessary.

5. Preventive and Population Health

5.1 Considers public health implications of infectious diseases.
5.2 Provides appropriate patient education on infection control and prevention.

6. Professionalism

6.1 Maintains confidentiality and delivers sensitive results appropriately.

7. General Practice Systems and Regulatory Requirements

7.1 Follows correct protocols for infectious disease notification and documentation.

9. Managing Uncertainty

9.1 Recognises limitations of testing and manages uncertain results appropriately.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises signs of severe infection requiring urgent intervention.

Competency at Fellowship Level

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