CCE-CBD-169

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses, and how would you confirm the diagnosis?

• Prompt: Discuss your reasoning based on history and examination.
• Prompt: Outline investigations you would order.

Q2. How would you explain the diagnosis to Kylie, and how would you address her concerns about STIs?

• Prompt: Provide reassurance and education on common causes of vaginitis.
• Prompt: Discuss STI screening as appropriate.

Q3. What is your immediate management plan for Kylie?

• Prompt: Include pharmacological and non-pharmacological treatments.
• Prompt: Include safety-netting advice.

Q4. What advice would you give Kylie on prevention of recurrent vulvovaginitis?

• Prompt: Discuss lifestyle and hygiene measures.
• Prompt: Discuss when to return for review.

Q5. How would you document this encounter, and what are your legal and ethical considerations?

• Prompt: Discuss relevant practice systems (e.g., recall for results).
• Prompt: Address confidentiality and consent.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are your differential diagnoses, and how would you confirm the diagnosis?

Answer:

In Kylie’s case, the primary differential diagnoses are:

1. Candidal vulvovaginitis: Suggested by the thick, white, curd-like discharge, pruritus, and erythema. Common in women using OCPs, with a history of antibiotic use or diabetes, though she has no known diabetes.
2. Bacterial vaginosis (BV): Usually associated with a thin, greyish discharge with a fishy odour—less likely given the description.
3. Trichomoniasis: Typically causes a frothy, green discharge and can cause pruritus and dysuria, but less likely in a monogamous woman with no STI history.
4. Contact dermatitis: Given her panty liner use, which may cause irritation, but not the discharge.
5. Lichen sclerosus or eczema: Considered with pruritus, but unlikely as discharge is not typical.

Confirmation of diagnosis:

• Speculum Examination Findings: Thick, adherent discharge supports candidal infection.
• High Vaginal Swab (HVS) for:
  • Microscopy: Presence of pseudohyphae or budding yeast cells confirms candidiasis.
  • pH testing: Candida usually does not alter vaginal pH (remains ≤4.5).
  • Whiff test: Negative in Candida but positive in BV.

Additional investigations may include:

• STI screen (chlamydia, gonorrhoea, trichomonas) if there is any doubt about sexual history.
• Blood glucose levels if recurrent candidiasis is suspected to exclude diabetes.

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Q2: How would you explain the diagnosis to Kylie, and how would you address her concerns about STIs?

Answer:

Explanation:

• “Kylie, based on your symptoms, examination, and the tests we’ve done, you have candidal vulvovaginitis, which is a common vaginal yeast infection. It’s not a sexually transmitted infection (STI), but rather an overgrowth of yeast that’s normally present in small amounts in the vagina.”
• “Triggers can include things like antibiotic use, hormonal changes from the pill, and wearing tight or non-breathable clothing. Sometimes it happens without a clear reason.”

Addressing STI concerns:

• “I understand you’re concerned about STIs. Your history of being in a long-term monogamous relationship makes this less likely, but we can do an STI screen to be thorough and reassure you.”
• “If the tests come back clear, we can be confident it’s a yeast infection and not sexually transmitted.”

Education:

• Discuss that candidiasis is not uncommon and not related to hygiene practices.

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Q3: What is your immediate management plan for Kylie?

Answer:

Pharmacological Treatment:

• First-line: Clotrimazole 1% cream (apply externally twice daily for 7–14 days) and/or Clotrimazole vaginal pessary (500mg stat).
• Alternative: Single dose oral fluconazole 150mg (not preferred if pregnant).

Non-pharmacological Treatment:

• Advise wearing cotton underwear, avoiding panty liners and tight clothing.
• Suggest avoiding irritants such as scented soaps and douches.
• Recommend drying the genital area thoroughly after bathing.

Safety-netting:

• Advise Kylie to return if:
  • Symptoms do not improve within 7 days.
  • Symptoms worsen.
  • Recurrent infections occur (≥4 episodes/year), which may require investigation for underlying conditions like diabetes.

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Q4: What advice would you give Kylie on prevention of recurrent vulvovaginitis?

Answer:

• Wear loose, breathable clothing and cotton underwear.
• Avoid using perfumed products in the genital area (soaps, bath products, wipes).
• After swimming or exercising, change out of wet clothes promptly.
• Maintain good glycaemic control if diabetic (test if recurrent).
• Probiotics may help restore vaginal flora but evidence is variable.
• Limit antibiotic use to when necessary.
• Monitor for recurrence and seek medical advice early if symptoms return.

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Q5: How would you document this encounter, and what are your legal and ethical considerations?

Answer:

Documentation:

• Record detailed history, examination findings, differential diagnoses.
• Document patient concerns and questions about STIs.
• Record patient education provided.
• Note management plan, including medications prescribed and instructions given.
• Record consent for STI screening if performed.
• Include safety-netting advice and planned follow-up.

Legal and Ethical Considerations:

• Confidentiality: Ensure privacy is maintained, particularly as this is a sensitive issue.
• Informed Consent: Obtain verbal consent for pelvic examination, STI screening, and any treatments.
• Follow-up and Recall Systems: Document follow-up plan to ensure results are communicated.
• Ensure culturally sensitive care, offering appropriate support if needed.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnoses reflecting history and examination findings.
• Clear communication explaining the diagnosis and addressing patient concerns empathetically.
• Evidence-based management following Australian guidelines (Therapeutic Guidelines: Antibiotic).
• Prevention strategies tailored to patient lifestyle and risk factors.
• Thorough documentation ensuring legal and ethical obligations are met.

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PITFALLS

• Failure to consider STIs despite the patient’s sexual history.
• Not obtaining informed consent before examinations or STI testing.
• Overlooking prevention advice, focusing only on treatment.
• Missing an opportunity for preventive health (e.g., diabetes screening if recurrent infections).

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REFERENCES

• Therapeutic Guidelines on Antibiotic (latest version)
• Australian STI Management Guidelines
• RACGP Red Book on Preventive activities in general practice

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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 from history and examination.
2.2 Orders or selects appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Systematically and efficiently tests diagnostic hypotheses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.
4.2 Provides appropriate patient education and counselling.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.
5.2 Adopts health promotion strategies.

6. Professionalism

6.1 Demonstrates respect, compassion, empathy, and caring in patient care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses practice systems effectively and safely.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively and explains it to patients.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and appropriately manages patients with potentially serious illnesses.

Competency at Fellowship Level

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