CCE-CBD-151

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses and how would you prioritise them?

• Prompt: Consider acute and chronic causes of unilateral leg swelling.
• Prompt: Explain reasoning for prioritisation.

Q2. What investigations would you organise or review in this setting?

• Prompt: Consider rural context and access issues.
• Prompt: What can be done urgently versus planned?

Q3. How would you explain the potential diagnosis and management options to Thomas?

• Prompt: Include safety netting, treatment, and follow-up.

Q4. How would you manage this case if imaging is not immediately available?

• Prompt: Explain management of diagnostic uncertainty.
• Prompt: Consider use of clinical prediction tools (e.g., Wells score).

Q5. What preventive health activities are appropriate during this consultation?

• Prompt: Consider cardiovascular risk and cancer screening.
• Prompt: Address modifiable risk factors.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses and how would you prioritise them?

Answer:

In Thomas Black’s case, the most likely differentials for his unilateral leg swelling include:

1. Deep Vein Thrombosis (DVT)
   • High on the differential list given the acute unilateral swelling, his occupation (long hours standing), prior smoking history, and age.
   • DVT is life-threatening due to the risk of pulmonary embolism (PE).
   • The Wells Score can be applied; factors like active cancer are absent, but swelling and prolonged immobility are present.
2. Chronic Venous Insufficiency
   • Possible due to his occupational standing and age but unlikely as this is acute onset.
3. Lymphoedema
   • Typically painless, non-pitting initially, and chronic. Less likely in this acute setting.
4. Cellulitis
   • Generally presents with redness, warmth, and systemic signs, which Thomas does not exhibit.
5. Ruptured Baker’s cyst
   • Presents with calf swelling but usually accompanied by pain and may mimic DVT. Less likely due to distribution.
6. Heart Failure
   • Bilateral swelling would be more typical, and Thomas has no dyspnoea at rest or orthopnoea.
7. Medication-induced oedema
   • No medications known for causing oedema (e.g., calcium channel blockers) are listed.

Prioritisation:

• DVT is the primary concern due to potential complications.
• Other diagnoses are less urgent but warrant consideration if DVT is excluded.

Q2: What investigations would you organise or review in this setting?

Answer:

Given the rural context and potential delay in accessing imaging:

1. Clinical Assessment
   • Apply the Wells Criteria to assess DVT probability.
   • If high probability, empirical anticoagulation may be started prior to imaging.
2. Investigations to arrange:
   • D-Dimer
     • If low or moderate Wells score and available, to rule out DVT.
     • Elevated levels are non-specific but suggestive in moderate/high probability.
   • Venous Doppler Ultrasound
     • Gold standard for diagnosis.
     • Organise at the nearest facility; assess logistics for transfer.
   • Full Blood Count (FBC), UEC, LFTs
     • Baseline before anticoagulation.
     • Rule out anaemia, renal impairment, or liver dysfunction.
   • Coagulation Profile
     • Required if anticoagulation is considered.
3. ECG and CXR
   • If respiratory symptoms worsen, consider PE workup.

Q3: How would you explain the potential diagnosis and management options to Thomas?

Answer:

• Explain the working diagnosis of DVT, outlining risks (e.g., clot travelling to lungs → PE).
• Use simple, clear language:
  • “A blood clot may be causing the swelling. It can be dangerous if it moves to your lungs.”
• Management plan:
  • Need for urgent imaging to confirm the diagnosis.
  • Discuss starting anticoagulation today, given high risk, even before confirming with ultrasound.
  • Outline risks and benefits of anticoagulation (bleeding risks vs clot risks).
• Safety net:
  • Seek immediate care if worsening breathlessness, chest pain, or coughing up blood.
  • Ensure follow-up arranged for ultrasound and specialist referral if indicated.
• Acknowledge challenges living rurally and ensure pragmatic planning for travel and care coordination.

Q4: How would you manage this case if imaging is not immediately available?

Answer:

• Use Wells Score to assess pre-test probability.
  • High probability → start empirical anticoagulation with low molecular weight heparin (LMWH) e.g., enoxaparin.
• Provide patient education:
  • Explain the rationale for starting treatment before confirmation.
• Organise transfer for ultrasound at the earliest opportunity.
• Monitor for signs of bleeding or clinical deterioration.
• If anticoagulation contraindicated, consider hospital admission for monitoring.
• Document discussions and clinical reasoning clearly.

Q5: What preventive health activities are appropriate during this consultation?

Answer:

• Cardiovascular risk assessment:
  • Lipids, BP, smoking cessation confirmed, but alcohol intake needs discussion.
  • Consider starting aspirin if cardiovascular risk high and no contraindications (but clarify why he’s on it already).
• Weight management advice
  • BMI of 29 → suggest strategies for weight loss.
• Cancer screening
  • Encourage bowel cancer screening.
  • Discuss prostate health, as appropriate for age.
• Vaccinations
  • Review and offer pneumococcal and Shingrix vaccines as appropriate.
• Health maintenance
  • Encourage regular GP reviews, especially due to his rural isolation.

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SUMMARY OF A COMPETENT ANSWER

• Demonstrates structured differential diagnosis with prioritisation.
• Applies Wells Score and understands DVT investigation pathways.
• Provides clear patient-centred explanations about diagnosis and management.
• Initiates empirical management in the context of rural healthcare limitations.
• Addresses preventive health measures, including cardiovascular and cancer screening.

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PITFALLS

• Failing to apply clinical decision rules (e.g., Wells Criteria).
• Delaying anticoagulation unnecessarily in high-risk patients.
• Inadequate safety netting for signs of PE.
• Neglecting rural health context, including access barriers.
• Missing preventive health opportunities during an acute visit.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Australian Therapeutic Guidelines: Cardiovascular and Venous Thromboembolism
• Wells Criteria for 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.

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.

5. Preventive and Population Health

5.1 Provides counselling on modifiable risk factors and behaviours.

6. Professionalism

6.1 Adopts a patient-centred approach in complex and challenging situations.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care effectively.

8. Procedural Skills

8.1 Performs procedural skills safely.

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 severe acute and chronic health conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural and remote healthcare needs and resources.

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Competency at Fellowship Level

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