CCE-CBD-163

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis and most likely diagnosis?

• Prompt: Explore the differential diagnosis for acute RUQ pain.
• Prompt: Explain your reasoning for cholecystitis as the primary diagnosis.

Q2. What is your immediate management plan for Margaret?

• Prompt: Discuss the urgency of referral to hospital.
• Prompt: Outline initial management while arranging transfer.

Q3. How would you address Margaret’s concerns about surgery and being away from the farm?

• Prompt: Explore communication strategies and shared decision-making.
• Prompt: Address rural health access issues.

Q4. What preventive health strategies should you offer Margaret?

• Prompt: Focus on cardiovascular risk management, weight management, and cancer screening.
• Prompt: Discuss dietary advice post-cholecystectomy.

Q5. What are the potential complications if this condition is not managed promptly?

• Prompt: Describe complications such as gallbladder perforation, sepsis, and pancreatitis.
• Prompt: Explain how you would monitor for these complications.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis and most likely diagnosis?

Detailed Answer:

In a patient presenting with acute right upper quadrant (RUQ) abdominal pain, there are several differential diagnoses to consider. A structured approach includes hepatobiliary, gastrointestinal, renal, and cardiopulmonary causes.

Differential Diagnoses:

• Acute cholecystitis (most likely): Based on Margaret’s classic presentation (RUQ pain radiating to the shoulder, nausea, vomiting, Murphy’s sign, ultrasound findings).
• Biliary colic: Often intermittent and less severe pain without signs of inflammation.
• Choledocholithiasis: Suggested by raised bilirubin and obstructive LFTs, though not clearly indicated in Margaret’s case.
• Acute pancreatitis: Consider if there was elevated lipase/amylase, and pain radiating to the back.
• Peptic ulcer disease: Epigastric pain, typically related to meals, but lacks supportive signs here.
• Hepatitis: Diffuse abdominal pain, abnormal LFTs but without gallbladder signs.
• Right lower lobe pneumonia or pleurisy: Can mimic RUQ pain but would have respiratory symptoms.
• Renal colic: Flank pain, haematuria but no abdominal signs.

Most Likely Diagnosis:

• Acute calculous cholecystitis: Margaret’s persistent RUQ pain following a fatty meal, vomiting, positive Murphy’s sign, elevated inflammatory markers (WCC, CRP), and ultrasound findings (gallstones, thickened gallbladder wall, pericholecystic fluid) confirm the diagnosis.

Reasoning:

• The acute onset, nature of the pain, systemic inflammatory response, and confirmatory imaging are consistent with acute cholecystitis.
• She has risk factors including obesity and female gender.
• Differential diagnoses are less likely due to the absence of typical features (e.g., no jaundice or significant hyperbilirubinaemia for choledocholithiasis).

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Q2: What is your immediate management plan for Margaret?

Detailed Answer:

Initial Stabilisation:

• Pain relief: IV opioids (e.g., morphine or fentanyl in titrated doses).
• Antiemetics: IV metoclopramide or ondansetron.
• NPO (nil by mouth): To rest the gastrointestinal tract.

Monitoring:

• Observations: HR, BP, RR, oxygen saturation, temperature.
• Fluid resuscitation: IV fluids (e.g., normal saline) to maintain hydration.

Antibiotics:

• Empirical IV antibiotics covering gram-negative and anaerobes. In a rural setting: IV ceftriaxone plus metronidazole or a single agent like piperacillin-tazobactam, according to local guidelines.

Referral and Transfer:

• Urgent referral to a surgical team at a regional hospital.
• Arrange safe transfer (consider RFDS if no local facilities).
• Communicate the urgency of transfer due to risk of perforation/sepsis.

Documentation and Communication:

• Clear handover including vitals, management, and pending tests.
• Address Margaret’s rural situation: planning care in consultation with retrieval teams.

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Q3: How would you address Margaret’s concerns about surgery and being away from the farm?

Detailed Answer:

Patient-Centred Communication:

• Acknowledge her fears regarding surgery and responsibilities.
• Provide empathetic reassurance regarding the necessity of urgent care to prevent complications.

Education:

• Explain the diagnosis, risks of non-treatment (perforation, sepsis), and benefits of early surgery.
• Outline expected recovery timelines.

Rural Context Considerations:

• Address transport issues (RFDS, ambulance).
• Plan discharge early to return home when medically safe.
• Discuss follow-up care with local GP and district nurses.

Support Network:

• Explore family/farm support options.
• Consider social work input for farm relief or other community resources.

Shared Decision-Making:

• Offer collaborative planning, ensuring Margaret feels informed and respected.

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Q4: What preventive health strategies should you offer Margaret?

Detailed Answer:

Cardiovascular Risk Management:

• Address obesity (BMI 32) with tailored dietary and exercise advice.
• Manage hyperlipidaemia (ongoing statin use).

Diabetes Risk Assessment:

• Screen for diabetes (given obesity and family history).

Cancer Screening:

• Encourage overdue cervical screening.
• Continue mammography as per guidelines.

Lifestyle Interventions:

• Nutritional counselling: Low-fat diet post-cholecystectomy.
• Physical activity: Encourage gradual increase post-recovery.

Immunisations:

• Review and update vaccinations (influenza, pneumococcal).

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Q5: What are the potential complications if this condition is not managed promptly?

Detailed Answer:

Complications of Untreated Acute Cholecystitis:

• Gallbladder perforation leading to peritonitis and sepsis.
• Empyema of the gallbladder (purulent infection).
• Gangrenous cholecystitis (necrosis of the gallbladder wall).
• Biliary peritonitis from bile leak.
• Cholangitis if stones migrate to the common bile duct.
• Pancreatitis secondary to gallstone migration.

Monitoring for Complications:

• Observe for signs of sepsis: hypotension, tachycardia, fever.
• Monitor LFTs, WCC, CRP for worsening inflammation.
• Watch for worsening pain, signs of peritonitis on examination.

Referral and Early Surgery:

• Early cholecystectomy within 72 hours reduces complication risk.

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SUMMARY OF A COMPETENT ANSWER

• Demonstrates a systematic differential diagnosis process.
• Provides evidence-based acute management in a rural setting.
• Uses empathetic communication to address patient concerns.
• Considers preventive health and chronic disease management.
• Recognises complications and explains monitoring and urgency clearly.

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PITFALLS

• Failure to recognise urgent surgical need, risking delayed transfer.
• Inadequate explanation of diagnosis and plan to patient.
• Overlooking preventive health during acute care discussions.
• Not addressing rural health access challenges.
• Missing early signs of complications like sepsis or perforation.

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REFERENCES

• RACGP Guidelines: Red Book 10th Edition on Preventive Health
• Australian Therapeutic Guidelines: Gastrointestinal (2024)
• Rural and Remote Health – RACGP Rural Position Statement

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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 findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Rationally selects, justifies and interprets relevant investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.
4.2 Provides appropriate emergency care.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses systems effectively to ensure patient safety and quality of care.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially life-threatening or serious conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural healthcare challenges, including limited access to emergency services.

Competency at Fellowship Level

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