CCE-CBD-134

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you explain the diagnosis of shingles to Margaret?

• Prompt: Explain the cause and nature of herpes zoster.
• Prompt: Address concerns about infectivity and risks to her grandchildren.
• Prompt: Discuss the natural course and prognosis.

Q2. What is your management plan for Margaret’s current shingles episode?

• Prompt: Discuss pharmacological and non-pharmacological options.
• Prompt: Address pain management and prevention of complications.

Q3. What are the indications for antiviral treatment in shingles?

• Prompt: Justify antiviral use in Margaret’s case.
• Prompt: Explain timing and benefits.

Q4. How would you address Margaret’s concerns about long-term nerve pain and prevention of recurrence?

• Prompt: Discuss risk factors and prevention of post-herpetic neuralgia.
• Prompt: Explain future vaccination options.

Q5. How would you manage follow-up and continuity of care for Margaret?

• Prompt: Discuss monitoring response to treatment.
• Prompt: Address opportunities for preventive health in future consultations.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you explain the diagnosis of shingles to Margaret?

Explanation of Condition:

• Herpes Zoster (Shingles) is caused by reactivation of the Varicella Zoster Virus (VZV), which remains dormant in nerve tissue after chickenpox infection.
• Triggers for reactivation include age-related immune decline or immunosuppression.
• Margaret’s age (64 years) and chronic conditions (diabetes) increase her risk.

Clinical Course:

• Begins with burning, tingling pain in a dermatomal distribution, followed by a blistering rash.
• Usually resolves within 2–4 weeks.

Transmission and Risks to Family:

• Shingles itself is not contagious, but the virus can be transmitted to non-immune individuals, causing chickenpox (not shingles).
• Risk is through direct contact with vesicular fluid, so covering the rash and strict hand hygiene is advised.
• Advise Margaret to avoid close contact with grandchildren (if they haven’t had chickenpox or are immunocompromised) until lesions crust over.

Prognosis and Complications:

• Pain typically improves with antiviral treatment if started early.
• Post-Herpetic Neuralgia (PHN) is a potential complication, particularly in older adults.

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Q2: What is your management plan for Margaret’s current shingles episode?

Antiviral Therapy:

• Prescribe Valaciclovir 1g TDS for 7 days (within 72 hours of rash onset).
• Explain it reduces the duration and severity of the outbreak and lowers the risk of PHN.

Pain Management:

• Simple analgesics: Paracetamol and/or NSAIDs.
• Consider amitriptyline or gabapentin if neuropathic pain is significant.
• Topical agents: Lidocaine patches if pain persists.

Skin Care:

• Keep rash clean and dry.
• Use non-adherent dressings to cover blisters.
• Advise cold compresses for symptomatic relief.

Infection Control:

• Emphasise hygiene and covering lesions.
• Avoid contact with at-risk individuals.

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Q3: What are the indications for antiviral treatment in shingles?

Indications:

• Age ≥50 years.
• Moderate to severe pain or rash.
• Involvement of the face/eye.
• Immunocompromised status.

Benefits:

• Reduces viral replication, severity, and duration of acute symptoms.
• Reduces risk and severity of PHN.
• Best initiated within 72 hours of rash onset, but can still be beneficial if new vesicles are appearing or complications are present.

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Q4: How would you address Margaret’s concerns about long-term nerve pain and prevention of recurrence?

Post-Herpetic Neuralgia (PHN):

• Discuss that PHN risk increases with age.
• Early antiviral therapy and optimal pain control reduce PHN risk.
• If PHN develops, treatments include tricyclic antidepressants, anticonvulsants, and topical agents.

Prevention:

• Recommend Zoster vaccine (Shingrix) post-recovery.
• Shingrix is recommended for all adults ≥50 years, even after a shingles episode, to prevent recurrence and reduce PHN risk.
• Can be given after complete recovery, typically at least 6 months post-episode.

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Q5: How would you manage follow-up and continuity of care for Margaret?

Short-term:

• Review in 48–72 hours to assess treatment response and pain control.
• Monitor for signs of secondary infection and new lesion formation.

Long-term:

• Arrange follow-up at 1 month to evaluate for PHN.
• Discuss vaccination plans.
• Review chronic disease management (diabetes and hypertension).
• Opportunistic screening as per guidelines.

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SUMMARY OF A COMPETENT ANSWER

• Explains shingles clearly, including cause, course, and transmission risk.
• Implements evidence-based treatment: antivirals, pain management, and skin care.
• Addresses patient concerns, focusing on PHN prevention and vaccine discussions.
• Demonstrates clear follow-up planning for acute management and prevention.
• Uses Australian guidelines, e.g., the RACGP and Australian Immunisation Handbook.

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PITFALLS

• Failing to offer antiviral therapy within the 72-hour window.
• Inadequate explanation of contagion risk, leading to patient anxiety.
• Overlooking PHN prevention and management.
• Neglecting vaccination advice post-recovery.
• Missing follow-up opportunities for chronic disease and preventive health.

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REFERENCES

• RACGP Red Book, 10th Edition
• Australian Immunisation Handbook on Shingles (Herpes Zoster)
• Murtagh’s General Practice, 8th Edition, Chapter on Infections and Skin Conditions.

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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 of healthcare and the full impact of their illness experience on their lives.
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 based on clinical presentation.
3.2 Demonstrates diagnostic reasoning and considers differentials.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan including pharmacological and non-pharmacological strategies.
4.2 Explains therapeutic options and engages in shared decision-making.

5. Preventive and Population Health

5.1 Provides advice on immunisation and prevention of complications.

6. Professionalism

6.1 Maintains patient-centred care with empathy and respect.

7. General Practice Systems and Regulatory Requirements

7.1 Adheres to vaccination protocols and documentation for Zoster vaccine eligibility.

9. Managing Uncertainty

9.1 Manages uncertainty in symptom control and risk of complications.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages potential complications such as post-herpetic neuralgia.

Competency at Fellowship Level

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