CCE-CBD-148

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and how would you explain the diagnosis to John?

• Prompt: Explore benign vs malignant causes of LUTS.
• Prompt: Communicate findings of DRE and PSA, addressing his concern about cancer.

Q2. What further investigations (if any) would you consider, and why?

• Prompt: Consider imaging, referral, and when these are appropriate in rural practice.
• Prompt: Justify ongoing PSA monitoring, bladder scans, or uroflowmetry.

Q3. Outline your management plan for John’s BPH.

• Prompt: Lifestyle modifications, medical therapy (alpha-blockers, 5-alpha reductase inhibitors), risks and benefits.
• Prompt: When to refer for specialist input and rural-specific considerations.

Q4. How would you address John’s concerns regarding travel and follow-up?

• Prompt: Discuss rural healthcare coordination and telehealth options.
• Prompt: Involve multidisciplinary care (pharmacist, nursing).

Q5. What preventive health measures would you implement for John?

• Prompt: Vaccinations, lifestyle advice, and chronic disease management in rural settings.
• Prompt: Cardiovascular risk assessment and bowel cancer screening.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and how would you explain the diagnosis to John?

Answer:

In John’s case, the primary differential diagnosis is Benign Prostatic Hyperplasia (BPH), given his classic lower urinary tract symptoms (LUTS), including hesitancy, weak stream, dribbling, and nocturia. His IPSS score of 16 suggests moderate LUTS. The DRE findings of a smooth, enlarged prostate without nodules, and a PSA level within age-adjusted normal range (4.2 µg/L) further support BPH rather than malignancy.

Other differential diagnoses to consider include:

• Prostate cancer: Less likely given the absence of nodules on DRE, normal PSA, and no red-flag symptoms (weight loss, bone pain).
• Urinary tract infection (UTI): Ruled out by normal urinalysis.
• Bladder outlet obstruction from other causes, e.g., urethral stricture—less likely without history of trauma or catheterisation.
• Neurogenic bladder: Less likely without neurological history.

Explanation to John: “John, the symptoms you’re experiencing are very common in men your age and are typically due to an enlarged prostate, which we call Benign Prostatic Hyperplasia. This means the prostate has grown but is not cancerous. Your examination was reassuring, and your PSA levels are within normal for your age, which helps us rule out prostate cancer for now. We will continue to monitor this, but your symptoms are manageable.”

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Q2: What further investigations (if any) would you consider, and why?

Answer:

Further investigations are tailored based on symptoms, initial findings, and patient preference.

1. Bladder ultrasound (already performed): Shows a post-void residual volume of 80 mL, which is within acceptable limits but worth monitoring over time.
2. Uroflowmetry (if available): To objectively measure urine flow rate and confirm obstruction.
3. Renal function tests (already normal): Important to assess for any obstructive uropathy.
4. Repeat PSA testing: As part of ongoing surveillance, generally every 12 months unless new symptoms arise.
5. Referral for urologist opinion: Not immediately necessary, but if symptoms worsen, if there’s rising PSA, haematuria, recurrent UTIs, or if medical management fails.

In a rural setting, accessibility to advanced testing may be limited, so coordinating with regional services or telehealth urology consults may be necessary.

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Q3: Outline your management plan for John’s BPH.

Answer:

Lifestyle and behavioural modifications (first-line):

• Reduce evening fluid intake, particularly caffeine and alcohol.
• Double voiding to help empty the bladder.
• Bladder training exercises.

Medical management:

• Alpha-blockers (e.g., tamsulosin): Improve urinary flow by relaxing prostatic smooth muscle. Onset within days.
• 5-alpha reductase inhibitors (e.g., finasteride): Reduce prostate volume, but slower onset (3-6 months). Useful if prostate volume >30 mL.
• Discuss side effects: dizziness (alpha-blockers), sexual dysfunction (finasteride).

Monitoring:

• Symptom assessment using IPSS.
• Regular PSA and renal function monitoring.
• Monitor for complications: urinary retention, infections.

When to refer:

• Failure of medical therapy.
• Significant post-void residual >100 mL.
• Suspicion of malignancy (rising PSA, abnormal DRE).

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Q4: How would you address John’s concerns regarding travel and follow-up?

Answer:

John lives in a rural area, so coordinated care is essential.

• Telehealth with urologists for non-procedural consultations.
• Shared care with rural GPs and practice nurses for regular monitoring.
• Coordinate medication supply through local pharmacies.
• Referral to community continence services if needed.
• Encourage early reporting of red-flag symptoms that may require urgent care.

Reassure John that routine management can be conducted locally, and referral to tertiary care is only necessary for procedural interventions (e.g., TURP).

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Q5: What preventive health measures would you implement for John?

Answer:

1. Cardiovascular risk assessment:
   • Regular BP checks, lipid profile, lifestyle advice (diet, exercise).
   • Consider absolute cardiovascular risk calculator.
2. Diabetes screening:
   • HbA1c if not recently done.
3. Bowel cancer screening:
   • Ensure enrolment in the National Bowel Cancer Screening Program.
4. Vaccinations:
   • Influenza, pneumococcal vaccines as per Australian Immunisation Handbook.
5. Bone health:
   • Consider osteoporosis screening, especially if risk factors.
6. Mental health:
   • Check for impact of symptoms on mental well-being and sleep.

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SUMMARY OF A COMPETENT ANSWER

• Clear explanation of BPH diagnosis, differentiation from prostate cancer.
• Appropriate consideration of investigations tailored to rural settings.
• Development of an evidence-based management plan, including lifestyle and pharmacological options.
• Addressing rural health challenges with coordinated care and telehealth.
• Emphasis on preventive health in the elderly rural male population.

PITFALLS

• Failing to differentiate BPH from prostate cancer confidently.
• Over-investigating without clear indications, especially in rural settings.
• Neglecting lifestyle advice and focusing only on medications.
• Ignoring patient concerns about travel and follow-up logistics.
• Missing preventive health opportunities, including bowel screening and vaccinations.

REFERENCES

• RACGP Guidelines
• National Institutes of Health on Urology
• Australian Prostate Cancer Guidelines
• Australian Immunisation Handbook
• HealthPathways (regional): BPH and LUTS management

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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 and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Provides appropriate advice and support.

5. Preventive and Population Health

5.1 Provides counselling on modifiable risk factors.

6. Professionalism

6.1 Adheres to relevant codes and guidelines.

7. General Practice Systems and Regulatory Requirements

7.1 Manages health records and referrals appropriately.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty and patient expectations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages significant and potentially serious conditions.

12. Rural Health Context (RH)

RH1.1 Coordinates multidisciplinary care in a rural context.

Competency at Fellowship Level

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