CCE-CBD-136

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses and how would you explain them to Maria?

Answer:

Maria presents with non-specific systemic symptoms of fatigue, malaise, intermittent low-grade fevers, mild weight loss, and poor concentration. She is also peri-menopausal and under significant psychosocial stress.

Differential Diagnoses can be grouped as follows:

1. Infectious causes
   • Chronic infections: e.g. tuberculosis (less likely in absence of risk factors)
   • Occult infections: e.g. urinary tract infection, dental infection, endocarditis (unlikely without focal signs)
2. Malignancy
   • Haematological: lymphoma or leukaemia (less likely without lymphadenopathy or splenomegaly)
   • Solid organ: breast, colorectal, or gynaecological cancers (considering family history and age)
3. Endocrine disorders
   • Thyroid dysfunction (ruled out via normal TSH)
   • Perimenopause contributing to fatigue, poor sleep, and mood symptoms
   • Adrenal insufficiency (rare, no hypotension or electrolyte imbalance)
4. Nutritional deficiencies
   • Iron deficiency anaemia (borderline ferritin), contributing to fatigue
   • B12 or folate deficiency (if diet is poor, not yet tested)
5. Psychosocial/Functional causes
   • Adjustment disorder/burnout due to caregiving stress and work pressures
   • Depression or anxiety (though no overt signs noted)
6. Autoimmune disorders
   • Systemic lupus erythematosus (SLE), polymyalgia rheumatica (PMR), or other connective tissue diseases (requires further serological workup)

Explaining to Maria:
“I understand you’re concerned about something serious like cancer. While it’s important to consider all possibilities, at this stage, the findings point more toward iron deficiency and possible stress-related fatigue, which can cause the symptoms you describe. We’ll work together to explore this further and rule out any serious underlying conditions.”

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Q2: What further investigations would you consider, and why?

Answer:

Primary Investigations (already completed):

• FBE (shows mild anaemia)
• CRP/ESR (elevated)
• TSH (normal)
• Iron studies (borderline low ferritin)

Additional Investigations:

1. Biochemical profile:
   • B12 and folate: To assess for other causes of anaemia
   • HbA1c and glucose: Rule out diabetes as a fatigue contributor
   • Coeliac serology: Given weight loss and iron deficiency
2. Infectious screen (if indicated):
   • Urine MCS (reassurance; normal dipstick so low yield)
   • CXR: To exclude occult infection, malignancy, or sarcoidosis
   • Hepatitis B, C, HIV screening if risk factors or ongoing uncertainty
3. Autoimmune screen:
   • ANA, ENA, Rheumatoid factor, anti-CCP (for systemic autoimmune disease)
   • CK (for PMR or myopathies) if clinically indicated
4. Women’s health review:
   • Pap smear: Overdue cervical screening
   • Mammogram: Due based on guidelines
   • Pelvic ultrasound: If there are menstrual changes or family history suggestive of ovarian malignancy

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Q3: What is your initial management plan for Maria?

Answer:

1. Address iron deficiency:

• Oral iron supplementation (ferrous sulfate 325 mg daily)
• Dietary advice: Increase iron-rich foods (red meat, leafy greens)
• Recheck ferritin and Hb in 6-8 weeks

2. Manage perimenopause symptoms (if contributing):

• Discuss lifestyle modifications (sleep hygiene, stress reduction, exercise)
• Offer counselling around menopause symptom management
• Consider hormone therapy (HRT) if indicated and no contraindications

3. Psychosocial support:

• Acknowledge caregiver burden
• Explore mental health impact and coping mechanisms
• Provide information about local carer support groups
• Discuss potential referral to a psychologist under a Mental Health Care Plan if needed

4. Health maintenance and prevention:

• Update cervical screening and mammography
• Reinforce vaccination status (flu, pneumococcal if appropriate)

5. Safety netting and follow-up:

• Review in 2-4 weeks or sooner if symptoms worsen
• Advise on red flags: worsening weight loss, night sweats, persistent fever, new pain

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Q4: How would you address Maria’s concern about cancer?

Answer:

• Validate her concerns: “It’s completely understandable to worry about these symptoms.”
• Reassure her with current evidence: “Based on your history and examination, there’s no indication of cancer at this time.”
• Explain the investigations: “We are performing appropriate tests to rule out serious illness.”
• Discuss the plan: “We’ll continue monitoring and if any concerns arise, we will act promptly.”
• Empathy: Acknowledge anxiety and offer support (psychological support, health coaching).
• Document concerns and discussions thoroughly.

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Q5: What challenges might you face in managing Maria in a rural setting?

Answer:

1. Access to services:
   • Limited access to specialists (e.g., gynaecologists, haematologists)
   • Delays in imaging and investigations
2. Continuity of care:
   • Patient may have difficulty attending follow-up due to distance and transport issues
3. Psychosocial burden:
   • Higher rates of caregiver stress and limited support networks
   • Increased mental health burden due to isolation
4. Coordination of care:
   • Need to liaise with regional health services
   • Possible need for telehealth consultation with specialists
5. Health literacy considerations:
   • Ensuring clear communication and shared decision-making

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SUMMARY OF A COMPETENT ANSWER

• Thorough differential diagnosis, covering infections, malignancy, endocrine, autoimmune, and psychosocial causes
• Appropriate further investigations, justified by symptoms and findings
• Comprehensive management plan, addressing both medical and psychosocial factors
• Empathetic communication, particularly regarding cancer concerns
• Recognition of rural health challenges and strategies to overcome them

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PITFALLS

• Failing to address Maria’s concerns about cancer
• Over-investigating without clear justification
• Neglecting mental health and psychosocial support
• Not considering rural-specific healthcare barriers
• Delaying important women’s health screening

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REFERENCES

• RACGP Guidelines
• Australian Menopause Society
• National Institutes of Health on Iron Deficiency Anaemia, Fatigue Assessment
• National Cervical Screening Program

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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 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 Generates and tests differential diagnoses
3.2 Selects appropriate investigations

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements a management plan

5. Preventive and Population Health

5.1 Provides appropriate lifestyle advice

6. Professionalism

6.1 Demonstrates respectful and culturally responsive care

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care with other healthcare providers when appropriate

9. Managing Uncertainty

9.1 Manages uncertainty and risk effectively

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages potentially serious conditions

12. Rural Health Context (RH)

RH1.1 Adapts healthcare delivery to resource limitations in rural settings

Competency at Fellowship Level

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