CCE-CBD-144.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differentials and how have you confirmed the diagnosis?

Answer:

Amanda Taylor presents with symptoms and signs highly suggestive of thyrotoxicosis. The primary differential diagnoses include:

• Graves’ disease
• Toxic multinodular goitre (TMNG)
• Subacute thyroiditis
• Factitious thyrotoxicosis

In Amanda’s case, the positive TSI (Thyroid Stimulating Immunoglobulin) strongly supports Graves’ disease as the diagnosis. TSI is specific for autoimmune thyroid stimulation. The diffuse goitre and exophthalmos further corroborate this diagnosis, as ophthalmopathy is largely unique to Graves’.

Other differentials and how they were excluded:

• TMNG typically presents in older patients and with nodularity rather than diffuse goitre. No nodules were palpated.
• Subacute thyroiditis often follows a viral illness and presents with a tender thyroid and elevated inflammatory markers, neither of which are present.
• Factitious thyrotoxicosis could be considered, but the presence of TSI and physical signs of ophthalmopathy make this unlikely.

Key points confirming Graves’ disease:

• Clinical features: anxiety, tremor, palpitations, diffuse goitre, ophthalmopathy
• Biochemistry: suppressed TSH, elevated T4 and T3
• Immunology: positive TSI

Referencing the Therapeutic Guidelines (Endocrinology) supports this diagnostic approach.

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Q2: How would you explain Amanda’s condition and treatment options in a patient-centred consultation?

Answer:

I would explain in clear, empathetic terms that Amanda has Graves’ disease, an autoimmune condition where antibodies overstimulate the thyroid, causing it to produce excessive thyroid hormones.

Treatment options:

1. Antithyroid medications (Carbimazole/Propylthiouracil):
   • First-line therapy in Australia, particularly for young women desiring pregnancy.
   • Typically commenced for 12-18 months.
   • Side effects include rash, agranulocytosis, and liver dysfunction.
   • Regular blood tests are needed for monitoring.
2. Radioactive iodine therapy:
   • Destroys thyroid tissue, often leading to hypothyroidism.
   • Not suitable if pregnancy is planned in the next 6-12 months.
   • Requires specialist coordination and may not be feasible in Amanda’s rural location without travel.
3. Surgery (Total thyroidectomy):
   • Considered for large goitres, compressive symptoms, or preference.
   • Requires lifelong thyroxine replacement.
   • Risks include hypocalcaemia and recurrent laryngeal nerve damage.

Addressing Amanda’s concerns:

• Fertility: Antithyroid drugs are preferred; PTU is safer in the first trimester.
• Occupation: Beta-blockers can alleviate palpitations and tremor, helping her continue teaching.
• Rural access: Ongoing management via telehealth with an endocrinologist.

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Q3: What are the potential complications of untreated thyrotoxicosis?

Answer:

Untreated thyrotoxicosis can lead to significant complications:

1. Cardiovascular:
   • Persistent tachycardia can lead to atrial fibrillation, increasing stroke risk.
   • Heart failure may develop due to chronic tachycardia.
2. Thyroid storm:
   • Life-threatening hypermetabolic state triggered by stress, infection, or surgery.
   • Presents with fever, confusion, tachyarrhythmias, and hypotension.
3. Osteoporosis:
   • Excess thyroid hormones increase bone turnover, leading to fragility fractures.
4. Reproductive health:
   • Menstrual irregularities, infertility, and increased miscarriage risk.
   • Poor control increases maternal-fetal risks during pregnancy.
5. Eye disease:
   • Progression of Graves’ ophthalmopathy, potentially leading to vision impairment.

Prompt management is crucial, as per Australian Therapeutic Guidelines.

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Q4: What are your next steps in management today?

Answer:

Immediate priorities include:

• Symptom relief:
  • Start Propranolol 20-40 mg TDS to control tachycardia, palpitations, and tremor.
• Initiate antithyroid medication:
  • Carbimazole 10-20 mg daily with monitoring for side effects.
  • Provide safety-netting advice: report fever or sore throat (agranulocytosis warning).
• Arrangements:
  • Refer to an endocrinologist, with telehealth if necessary.
  • Baseline blood tests: FBC, LFT, baseline TSH-receptor antibodies.
• Patient education:
  • Explain potential side effects and importance of medication adherence.
  • Discuss contraception and future pregnancy planning.
• Follow-up:
  • Review bloods and symptoms in 2-4 weeks.
  • Continue TFT monitoring every 4-6 weeks.

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Q5: How would you coordinate ongoing care in a rural practice?

Answer:

Ongoing management requires a team-based and flexible approach:

• Telehealth consultations with an endocrinologist, avoiding travel.
• Regular TFT monitoring in practice or local pathology.
• Ensure medication compliance and screen for adverse effects.
• Supportive care: Address emotional wellbeing, offer counselling if needed.
• Pre-conception counselling:
  • Stabilise thyroid function before pregnancy.
  • Switch to PTU if pregnancy occurs while on carbimazole.
• Monitoring for hypothyroidism after treatment.
• Education on symptoms of relapse or complications.
• GP Management Plan may be useful for chronic disease management and to access Medicare-subsidised allied health services.

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SUMMARY OF A COMPETENT ANSWER

• Clearly identifies Graves’ disease as the diagnosis based on clinical and investigative findings.
• Explains treatment options in a patient-centred manner, addressing fertility and rural access issues.
• Highlights complications of untreated thyrotoxicosis, including thyroid storm and cardiovascular risks.
• Initiates symptomatic treatment and antithyroid medications promptly.
• Coordinates ongoing care in a rural setting using telehealth and local resources.

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PITFALLS

• Failing to address fertility concerns, leading to patient anxiety.
• Omitting beta-blocker initiation, leaving symptoms unmanaged.
• Overlooking agranulocytosis risk with antithyroid drugs.
• Inadequate follow-up arrangements, especially in rural practice.
• Not considering patient’s occupation and lifestyle when planning management.

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REFERENCES

• Therapeutic Guidelines on Endocrinology
• RACGP Red Book Preventive Guidelines
• Australian Endocrine Society on Management of Thyroid Disease

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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, considering the patient’s context and life stage.

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 evidence-based advice, education, and intervention for health improvement.

6. Professionalism

6.1 Adheres to ethical and professional standards, including confidentiality and respect.

7. General Practice Systems and Regulatory Requirements

7.1 Uses health information systems for quality improvement.

8. Procedural Skills

8.1 Demonstrates the use of appropriate procedural skills.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical decision-making.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients at risk of significant illness.

12. Rural Health Context (RH)

RH1.1 Understands and addresses rural access barriers, including telehealth options.

Competency at Fellowship Level

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