CCE-CBD-142

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses and what is your most likely diagnosis?

• Prompt: Discuss your clinical reasoning.
• Prompt: Explain how you will confirm your diagnosis.

Q2. How would you manage Emma’s condition today?

• Prompt: Include pharmacological and non-pharmacological treatment.
• Prompt: Discuss the role of partner notification and treatment.

Q3. What are the potential complications of this condition, and how would you counsel Emma about them?

• Prompt: Discuss long-term reproductive health implications.
• Prompt: Address Emma’s concerns about infertility.

Q4. What are the preventive health strategies you would recommend to Emma?

• Prompt: Discuss contraception, STI prevention, and future screening.

Q5. How would you address Emma’s concerns about confidentiality and stigma in the rural setting?

• Prompt: Discuss maintaining patient privacy in small communities.
• Prompt: Explore strategies for supportive communication.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses and what is your most likely diagnosis?

A competent candidate will first acknowledge the presenting symptoms and clinical findings: abnormal vaginal discharge, cervical motion tenderness, and a history of a new sexual partner.
Differential diagnoses include:

• Pelvic Inflammatory Disease (PID) – most likely diagnosis, based on cervical motion tenderness, mucopurulent discharge, and sexual history.
• Cervicitis – potentially isolated infection with chlamydia or gonorrhoea.
• Vaginitis – e.g., bacterial vaginosis or trichomoniasis, although cervical tenderness suggests upper genital tract involvement.
• Endometritis – less likely without systemic symptoms.
• Physiological discharge – unlikely given the findings.

Reasoning: PID is the most likely diagnosis given the symptoms and examination findings consistent with upper genital tract infection. The CDC and Australian STI Management Guidelines state that cervical motion tenderness plus mucopurulent discharge and risk factors warrant empirical treatment for PID.
Confirmatory investigations: NAAT testing for chlamydia and gonorrhoea, high vaginal swabs, and urine PCR. Pregnancy exclusion is confirmed with a negative test.

Q2: How would you manage Emma’s condition today?

A competent candidate will implement empirical treatment immediately:

• Antibiotics as per Australian STI Guidelines (2023):
  • Ceftriaxone 500 mg IM single dose
  • Doxycycline 100 mg BD for 14 days
  • Metronidazole 400 mg BD for 14 days
• Provide pain relief (e.g., paracetamol, NSAIDs if no contraindications).
• Advise no sexual intercourse until treatment completion and partner treatment.
• Discuss partner notification: advise her partner(s) to be tested and treated even if asymptomatic.
• Provide education about STIs, transmission, and prevention.
• Offer psychosocial support, considering confidentiality concerns.
• Arrange follow-up in 48-72 hours to reassess.
• Referral to sexual health services if complications or lack of improvement.

Q3: What are the potential complications of this condition, and how would you counsel Emma about them?

Complications include:

• Infertility due to tubal scarring.
• Chronic pelvic pain.
• Ectopic pregnancy.
• Recurrent PID.

Counselling:

• Early treatment reduces risks.
• Reassure Emma that many women with prompt treatment have no fertility issues.
• Encourage regular screening and safe sex practices.
• Explore and address anxiety and misconceptions about PID and infertility.
• Document discussion and consent for treatment.

Q4: What are the preventive health strategies you would recommend to Emma?

• Regular STI screening, particularly after new partners.
• Discuss condom use to reduce STI risk.
• Ensure vaccination status is up to date (HPV already done).
• Review and discuss long-term contraception, including risks and benefits (currently on OCP).
• Promote healthy lifestyle (e.g., smoking cessation, though non-smoker).
• Encourage routine cervical screening as per national guidelines.

Q5: How would you address Emma’s concerns about confidentiality and stigma in the rural setting?

• Explain the privacy policies of the clinic, including strict confidentiality.
• Reassure Emma her information is protected under Australian Privacy Principles.
• Discuss discreet methods for partner notification, such as online tools like Let Them Know.
• Provide a safe, non-judgemental environment for discussion.
• Offer ongoing support and counselling services.
• Document her preferences regarding communication and partner involvement.

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SUMMARY OF A COMPETENT ANSWER

• Demonstrates diagnostic reasoning, prioritising PID.
• Initiates empirical treatment per guidelines while awaiting results.
• Educates and reassures about complications and fertility.
• Promotes preventive strategies, including STI screening and contraception.
• Addresses confidentiality concerns, respecting patient privacy and autonomy.

PITFALLS

• Failure to treat empirically while awaiting test results.
• Inadequate partner notification advice, risking reinfection.
• Overlooking Emma’s privacy concerns, which could deter future healthcare engagement.
• Neglecting to arrange follow-up, missing treatment failures or complications.
• Inappropriate reassurance about fertility without discussing potential risks.

REFERENCES

• Australian STI Management Guidelines
• CDC PID Guidelines
• RACGP Red Book Preventive Guidelines

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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 judgment.

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.

8. Procedural Skills

8.1 Performs procedures in a safe and effective manner appropriate to general practice.

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 patients with potentially serious or life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates knowledge of rural health practice, including accessibility and limitations of services.

Competency at Fellowship Level

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