CCE-CBD-138

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your diagnosis and how would you explain this to Amanda?

• Prompt: Use patient-centred communication
• Prompt: Address Amanda’s concerns about fertility and sexually transmitted infections

Q2. What are your management options for Amanda’s current episode?

• Prompt: Include pharmacological and non-pharmacological treatments
• Prompt: Consider rural practice limitations

Q3. How would you address Amanda’s recurrent vulvovaginal candidiasis?

• Prompt: Discuss prevention strategies
• Prompt: Discuss follow-up and escalation options

Q4. What differentials would you consider if Amanda’s symptoms persist despite appropriate treatment?

• Prompt: Discuss other infectious and non-infectious causes
• Prompt: Consider the need for further investigations or referrals

Q5. How would you incorporate preventive health and education into this consultation?

• Prompt: Include reproductive health, STI screening, and lifestyle factors
• Prompt: Consider future pregnancy planning

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your diagnosis and how would you explain this to Amanda?

Diagnosis:

• Amanda has acute vulvovaginal candidiasis, confirmed by clinical findings and vaginal swab positive for Candida albicans.
• Given the history of ≥4 episodes in 12 months, she meets criteria for recurrent vulvovaginal candidiasis (RVVC).

Explanation to Amanda:

• Empathetic communication: Acknowledge Amanda’s discomfort and concerns.
• Simple, clear language: Explain that this is a common yeast infection caused by an overgrowth of a normally harmless yeast, Candida albicans.
• Reassurance: It’s not a sexually transmitted infection and doesn’t impact fertility.
• Precipitating factors: Recent antibiotic use may have disrupted her natural vaginal flora, leading to this overgrowth.
• Discuss her risk factors: Antibiotic use, possible tight clothing, high sugar intake (if present).
• Education: Emphasise it’s treatable and strategies exist to prevent recurrences.

Q2: What are your management options for Amanda’s current episode?

Pharmacological options:

• Topical antifungal: Clotrimazole 1% cream for 7 days or 6-day pessary.
• Oral antifungal: Single-dose fluconazole 150 mg (avoid in pregnancy).
• Combination of oral and topical if symptoms severe.

Non-pharmacological advice:

• Keep the genital area dry and avoid tight-fitting clothing.
• Use mild soap alternatives, avoid douching.
• Consider probiotics, though evidence is variable.

Rural considerations:

• Provide a script for repeat treatments if travel is difficult.
• Discuss telehealth follow-ups.

Q3: How would you address Amanda’s recurrent vulvovaginal candidiasis?

Long-term management strategies:

• Induction therapy: Fluconazole 150 mg every 3 days for 3 doses.
• Maintenance therapy: Fluconazole 150 mg weekly for 6 months.
• Identify and modify risk factors: Avoid unnecessary antibiotics, manage diabetes (already ruled out), promote good vulval care.
• Monitor for side effects: Liver function if on long-term fluconazole.
• Encourage partner involvement if symptomatic, though not routinely treated.

Follow-up plan:

• Review symptoms after induction phase.
• Regular check-ins via telehealth or in-person as feasible.

Q4: What differentials would you consider if Amanda’s symptoms persist despite appropriate treatment?

Infectious causes:

• Bacterial vaginosis
• Trichomoniasis
• Herpes simplex virus (HSV)
• Resistant non-albicans Candida species (e.g., Candida glabrata)

Non-infectious causes:

• Vulval dermatitis or eczema
• Lichen sclerosus
• Vulvodynia
• Hypoestrogenism (unlikely at Amanda’s age unless related to other factors)

Investigations:

• Repeat vaginal swab with culture and sensitivity
• Consider biopsy if skin changes present
• Diabetes screening (already completed but repeat if risk factors change)

Q5: How would you incorporate preventive health and education into this consultation?

Sexual health:

• Offer comprehensive STI screening for Amanda and her partner for reassurance.
• Discuss contraception options, particularly if planning pregnancy soon.

Pre-pregnancy planning:

• Ensure rubella immunity, folic acid supplementation, review medications.

Lifestyle and preventive care:

• Educate on vaginal health: avoiding irritants, practising good hygiene.
• Encourage healthy diet: lower refined sugars (though evidence linking diet to candidiasis is limited).
• Promote self-examination awareness and regular cervical screening.

---

SUMMARY OF A COMPETENT ANSWER

• Clear explanation of vulvovaginal candidiasis, including cause and reassurance about fertility/STIs
• Comprehensive acute management, considering both pharmacological and non-pharmacological options
• Appropriate plan for recurrent infections, including maintenance therapy and addressing modifiable risk factors
• Broad differential diagnosis when symptoms persist, with a logical approach to further investigation
• Preventive health strategies, including STI screening, reproductive health, and lifestyle advice

---

PITFALLS

• Failing to reassure Amanda about fertility and non-STI nature of candidiasis
• Overlooking the need for maintenance therapy in recurrent cases
• Neglecting partner considerations in recurrent infections
• Missing alternative diagnoses like lichen sclerosus or vulvodynia
• Not addressing Amanda’s rural healthcare access limitations
• Forgetting preventive health, especially preconception advice and STI screening

---

REFERENCES

• RACGP Red Book on Preventive activities in general practice
• Therapeutic Guidelines on Antibiotic (latest edition): Vulvovaginal candidiasis management
• Australian STI Management Guidelines
• RACGP Women’s Health Curriculum

---

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 Gathers and interprets information relevant to the presentation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes appropriate treatments.

5. Preventive and Population Health

5.1 Provides health promotion and disease prevention strategies.

6. Professionalism

6.1 Maintains confidentiality and respects patient autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Adheres to safe prescribing practices and evidence-based guidelines.

9. Managing Uncertainty

9.1 Manages common presentations and considers red flags.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies when a presentation requires further investigation or referral.

11. Aboriginal Health Context (AH)

AH1.1 Demonstrates cultural awareness (not primary focus but included in communication and approach).

12. Rural Health Context (RH)

RH1.1 Provides care with consideration of rural practice limitations.

Competency at Fellowship Level

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