CCE-CBD-140

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis in this case?

• Prompt: Explore DVT as a primary concern
• Prompt: Consider differential diagnoses like cellulitis, muscle strain, Baker’s cyst rupture, chronic venous insufficiency
• Prompt: Explain why other diagnoses are less likely

Q2. What immediate investigations and referrals would you arrange?

• Prompt: Discuss the role of Wells criteria
• Prompt: Explain why a Doppler ultrasound is indicated
• Prompt: Outline the potential need for D-dimer testing

Q3. What is your management plan if DVT is confirmed?

• Prompt: Outline anticoagulation options (DOACs vs. warfarin)
• Prompt: Consider referral pathways (ED vs outpatient)
• Prompt: Advise on activity modification and safety netting

Q4. How would you counsel David regarding preventing future episodes?

• Prompt: Discuss modifiable risk factors
• Prompt: Address smoking cessation, weight management, and physical activity
• Prompt: Outline preventive measures during flights or long periods of immobility

Q5. How would you address David’s concerns about pulmonary embolism and the risks of anticoagulation?

• Prompt: Provide clear information about symptoms of PE
• Prompt: Discuss the risks vs benefits of anticoagulation
• Prompt: Provide written information and follow-up plan

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis in this case?

Answer:

The primary concern in this scenario is Deep Vein Thrombosis (DVT), given the patient’s clinical features and risk factors.

Most Likely Diagnosis:

• Proximal lower limb DVT, involving the left popliteal or femoral veins.

Key Supporting Features:

• Sudden onset of unilateral calf swelling and pain.
• Asymmetrical calf circumference (3 cm difference).
• Positive Homan’s sign (although nonspecific).
• Recent prolonged immobility (24-hour flight).
• Additional risk factors: age >50, smoking, hypertension, elevated BMI.

Differential Diagnoses:

1. Cellulitis:
   • Unlikely: no erythema or systemic signs (fever).
2. Ruptured Baker’s cyst:
   • Less likely: no history of knee issues or known Baker’s cyst, no bruising/ecchymosis.
3. Muscle strain/tear:
   • Less likely: no trauma or increased activity.
4. Chronic venous insufficiency:
   • Less likely: acute symptoms and unilateral presentation.
5. Superficial thrombophlebitis:
   • Less likely: no palpable superficial cord.

Conclusion:
The combination of risk factors, clinical signs, and recent travel makes DVT the most probable diagnosis.

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Q2: What immediate investigations and referrals would you arrange?

Answer:

1. Clinical Risk Assessment:

• Use Wells score for DVT:
  • Active cancer: No (0)
  • Paralysis/paresis: No (0)
  • Recently bedridden: No (0)
  • Localised tenderness: Yes (+1)
  • Entire leg swollen: No (0)
  • Calf swelling >3 cm: Yes (+1)
  • Pitting oedema: No (0)
  • Collateral superficial veins: No (0)
  • Alternative diagnosis less likely: Yes (+1)
• Wells score = 3 (high risk).

2. Investigations:

• Urgent Duplex Doppler Ultrasound of the left leg.
  • Non-invasive and highly sensitive/specific.
• D-dimer test:
  • Optional if Wells score was low/intermediate. In this case, not necessary due to high pre-test probability.
• Baseline bloods:
  • FBC, EUC, LFTs (prior to anticoagulation).
  • Coagulation studies.

3. Referral:

• If DVT confirmed, refer to Emergency Department or arrange outpatient anticoagulation initiation depending on local pathways.

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Q3: What is your management plan if DVT is confirmed?

Answer:

1. Immediate Anticoagulation:

• Direct Oral Anticoagulants (DOACs) (e.g., rivaroxaban or apixaban) as first-line.
  • Rivaroxaban regimen: 15 mg BID for 21 days, then 20 mg daily.
• Warfarin + LMWH is an alternative if DOAC contraindicated.

2. Patient Education:

• Explain treatment duration: typically 3 months, reassess risk for continuation.
• Discuss bleeding risks and signs to monitor.
• Advise on activity: avoid prolonged immobility; elevate leg to reduce swelling.

3. Follow-up:

• 1-week review for clinical response and side effects.
• Consider thrombophilia screen if unprovoked DVT or family history.

4. Safety Netting:

• Educate about pulmonary embolism signs (chest pain, dyspnoea).
• Provide emergency contacts.

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Q4: How would you counsel David regarding preventing future episodes?

Answer:

1. Risk Factor Modification:

• Smoking cessation: offer Quitline, NRT, or pharmacotherapy.
• Weight reduction: dietician referral, encourage physical activity.
• Hypertension control: optimise medication adherence and lifestyle.

2. Preventive Strategies for Travel/Immobility:

• Regular mobility every 1-2 hours during flights.
• Compression stockings if high risk.
• Stay hydrated and avoid alcohol/dehydration.
• Consider prophylactic anticoagulation if future high-risk events.

3. Education:

• Importance of recognising recurrence symptoms.
• Maintain regular GP reviews.

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Q5: How would you address David’s concerns about pulmonary embolism and the risks of anticoagulation?

Answer:

1. Explain PE Risks:

• DVT can lead to pulmonary embolism, which is potentially life-threatening.
• Explain symptoms: chest pain, shortness of breath, coughing blood.

2. Anticoagulation Risks vs Benefits:

• Bleeding risk is low but present.
• Anticoagulation significantly reduces clot extension and embolisation.

3. Reassurance & Plan:

• Close monitoring for side effects.
• Provide written information and encourage questions.
• Emergency plan: when and how to seek immediate help.

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SUMMARY OF A COMPETENT ANSWER

• Thorough differential diagnosis with appropriate reasoning.
• Accurate use of Wells criteria and appropriate investigations.
• Evidence-based management plan with clear explanation.
• Focus on preventive health and risk factor modification.
• Effective communication, including patient-centred counselling and reassurance.

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PITFALLS

• Failing to calculate or incorrectly applying the Wells score.
• Omitting Doppler ultrasound or relying solely on D-dimer in high-risk patients.
• Inadequate explanation of anticoagulation risks/benefits.
• Not addressing lifestyle factors (smoking, weight).
• Lack of safety netting advice regarding pulmonary embolism signs.

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REFERENCES

• RACGP Guidelines
• Therapeutic Guidelines on Cardiovascular
• HealthDirect Australia on DVT
• UpToDate on Management of DVT

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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 Gathers and interprets information about health needs, including the patient’s life stage and context.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health needs.
3.2 Demonstrates diagnostic reasoning and clinical judgement.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements patient-centred management plans.
4.2 Applies evidence-based medicine and shared decision-making.

5. Preventive and Population Health

5.1 Provides health promotion and disease prevention strategies.

6. Professionalism

6.1 Adheres to ethical, legal, and professional standards.

7. General Practice Systems and Regulatory Requirements

7.1 Practices within the Australian health care system and understands referral pathways.

9. Managing Uncertainty

9.1 Manages uncertainty and risk in decision-making.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and responds to potentially life-threatening conditions.

Competency at Fellowship Level

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