EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Emily’s presentation?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative diagnoses should be considered?

Q2. What red flags would indicate a more serious condition requiring escalation of care?

• Prompt: What examination findings would prompt hospital referral?
• Prompt: How would you assess for systemic involvement?

Q3. How would you manage Emily’s condition?

• Prompt: Does she require antiviral, antibiotic, or symptomatic treatment?
• Prompt: What advice would you give her parents regarding school attendance?

Q4. How would you counsel Emily’s mother regarding her concerns about measles?

• Prompt: How would you explain vaccine protection and likelihood of measles?
• Prompt: What reassurance or additional steps might be appropriate?

Q5. What preventive strategies can be implemented to reduce transmission of infectious rashes?

• Prompt: What hygiene measures should be emphasised?
• Prompt: When should families seek medical attention for new rashes?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Emily’s presentation?

Emily’s most likely diagnosis is a viral exanthem, considering her generalised maculopapular rash, mild fever, and recent school exposure. Given her vaccination history, measles is unlikely, but parents may still have concerns.

Common viral causes include:

1. Roseola (Human Herpesvirus 6/7) – Post-febrile pink maculopapular rash starting on the trunk.
2. Rubella – Mild fever, postauricular lymphadenopathy, and a pink, non-confluent rash.
3. Erythema infectiosum (Parvovirus B19, “slapped cheek”) – Facial rash with lacy exanthem on limbs.
4. Hand, foot, and mouth disease (Coxsackievirus) – Rash on hands, feet, and oral ulcers.

Non-viral differentials include:

• Scarlet fever (GAS infection) – Strawberry tongue, sandpaper rash.
• Kawasaki disease – Prolonged fever, conjunctivitis, extremity changes.
• Meningococcal sepsis – Purpuric rash, systemic symptoms (red flag).

A focused history and examination will help rule out serious causes requiring urgent management.

---

Q2: What red flags would indicate a more serious condition requiring escalation of care?

Red flags necessitating urgent assessment or referral include:

• Toxic appearance – Lethargy, poor perfusion, altered consciousness.
• Meningococcal signs – Petechiae/purpura, neck stiffness, photophobia.
• High fever (>39°C) with no rash blanching – Suggests severe systemic illness.
• Severe pain, blistering, or necrotic lesions – Consider Staphylococcal scalded skin syndrome.
• Unresponsive rash after antipyretics – May indicate vasculitis or Kawasaki disease.

A child with any of these findings requires urgent hospital referral for further assessment and possible intravenous therapy.

---

Q3: How would you manage Emily’s condition?

Supportive care for viral exanthem:

• Reassurance – Self-limiting condition.
• Symptomatic relief – Paracetamol for fever, antihistamines for itching.
• Hydration and rest – Encourage fluids and monitoring for new symptoms.
• School exclusion – Until afebrile for 24 hours, except for hand-foot-mouth (exclusion until lesions dry).

When to consider antibiotics?

• If scarlet fever is suspected – Treat with penicillin or amoxicillin.

Follow-up plan:

• Review in 2-3 days if no improvement.
• Return immediately if new symptoms develop (fever spike, irritability, or rash worsening).

---

Q4: How would you counsel Emily’s mother regarding her concerns about measles?

1. Address concerns empathetically
   • “I understand your concern about measles, especially with recent news reports.”
2. Reassure based on vaccination status
   • “Emily has had both MMR doses, which provide over 95% protection.”
   • “Her rash lacks Koplik spots and conjunctivitis, making measles unlikely.”
3. Explain why testing is unnecessary
   • “Her symptoms align more with roseola or another common viral rash.”
4. Provide safety-netting advice
   • “Monitor for high fever, breathing difficulties, or worsening rash.”
   • “Seek review if her rash changes or if she appears unwell.”

---

Q5: What preventive strategies can be implemented to reduce transmission of infectious rashes?

1. Hygiene education
   • Frequent handwashing and avoiding shared personal items.
2. School exclusion policies
   • Children should stay home if febrile or until lesions are dry (e.g., hand-foot-mouth disease).
3. Vaccination updates
   • “Emily is fully vaccinated, but ensure younger siblings stay up to date.”
4. Parental awareness of red flags
   • Teach parents when to seek medical attention for new rashes.

---

SUMMARY OF A COMPETENT ANSWER

• Systematic differential diagnosis, distinguishing common viral rashes from serious bacterial infections.
• Identification of red flags indicating urgent hospital referral.
• Appropriate management, balancing supportive care vs. need for antibiotics.
• Clear and empathetic counselling to alleviate parental concern about measles.
• Public health considerations, including school exclusion and hygiene education.

PITFALLS

• Failing to identify serious causes, leading to delayed escalation of care.
• Overprescribing antibiotics for self-limiting viral exanthems.
• Inadequate parental reassurance, causing unnecessary anxiety.
• Not providing safety-netting advice, missing rash progression or complications.
• Neglecting public health aspects, such as school exclusion policies.

REFERENCES

• RACGP – RACGP Guidelines on Drug Reactions and Allergy Management
• GP Exams – Rash

---

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 Explains the possible causes of rash in simple terms to the parent and child.
1.2 Provides clear safety-netting advice for parents regarding rash progression.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history of rash onset, associated symptoms, and exposures.
2.2 Performs an appropriate skin examination and identifies key rash features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common viral exanthems and bacterial skin infections.
3.2 Recognises signs of a serious illness requiring escalation of care.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan based on the likely cause.
4.2 Identifies when antibiotics, antivirals, or other treatments are needed.

5. Preventive and Population Health

5.1 Provides education on infection prevention and hygiene measures.

6. Professionalism

6.1 Provides reassurance while addressing parental concerns about infectious rashes.

7. General Practice Systems and Regulatory Requirements

7.1 Follows correct protocols for notifying notifiable diseases when applicable.

9. Managing Uncertainty

9.1 Recognises when further investigation or specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies systemic involvement requiring urgent medical intervention.

Competency at Fellowship Level

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