CCE-CBD-170

EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: Explore differential diagnoses
• Prompt: Discuss how you confirm cataract diagnosis

Q2. How would you explain the diagnosis and management options to Mr Thompson?

• Prompt: Provide a patient-friendly explanation of cataracts
• Prompt: Discuss conservative vs surgical management

Q3. What factors would you consider before referring Mr Thompson for cataract surgery?

• Prompt: Discuss clinical and social factors
• Prompt: Address risks and benefits of surgery

Q4. How would you manage Mr Thompson’s concerns regarding the surgery?

• Prompt: Address anxiety and misconceptions
• Prompt: Provide information on outcomes and risks

Q5. What preventive measures and follow-up would you recommend post-surgery?

• Prompt: Preventive strategies for eye health
• Prompt: Outline post-op care and long-term follow-up

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Answer:

The most likely diagnosis in Mr Robert Thompson’s case is age-related bilateral cataracts, given his symptoms and examination findings. His main complaints—gradual vision loss, difficulty with night driving due to glare, and problems with reading—are classic symptoms of cataract.

Differential diagnoses to consider include:

• Age-related macular degeneration (AMD): Particularly with family history. However, his fundoscopic examination is unremarkable.
• Open-angle glaucoma: Asymptomatic early stages, but his intraocular pressures are normal, and there is no evidence of optic disc cupping.
• Diabetic retinopathy: No history of diabetes and no retinal changes noted.

Confirmation of diagnosis:

• Comprehensive eye examination including slit-lamp biomicroscopy, typically performed by an optometrist or ophthalmologist, is the gold standard to assess lens opacity.
• Visual acuity testing: Already demonstrates decreased acuity (6/18 and 6/24).
• Red reflex diminished and lens opacities visible on fundoscopy further support the diagnosis.
• Pupil responses and intraocular pressures are normal, helping rule out more urgent ocular pathology.

A referral to an ophthalmologist for comprehensive assessment and surgical discussion is appropriate once the diagnosis is confirmed.

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Q2: How would you explain the diagnosis and management options to Mr Thompson?

Answer:

Explaining the diagnosis: “Mr Thompson, you have a common age-related eye condition called cataracts. This occurs when the clear lens inside your eye becomes cloudy, affecting the way light enters and is focused onto the back of your eye, leading to blurry vision.”

Management options:

• Non-surgical:
  • Optimise prescription glasses.
  • Improve lighting at home.
  • Use magnifiers for reading.
  • Limit night driving.
• Surgical:
  • Cataract surgery is recommended when your vision interferes with daily activities, as in your case with reading and driving.
  • It’s a day procedure performed under local anaesthetic.
  • The cloudy lens is removed and replaced with a clear artificial lens (intraocular lens).

Discuss risks and benefits:

• High success rate (over 95% improvement in vision).
• Risks are low but include infection, bleeding, or retinal detachment (rare).

I would provide reassurance and address his anxiety, encouraging him to ask questions and explore informational resources.

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Q3: What factors would you consider before referring Mr Thompson for cataract surgery?

Answer:

• Clinical factors:
  • Visual impairment severity: Mr Thompson’s acuity is below driving standards.
  • Bilateral cataracts: Both eyes affected, though surgery is typically done sequentially.
  • General health: Hypertension well-controlled, no major surgical risks identified.
• Social factors:
  • Living alone and driving reliance: Improving vision is key for his independence.
  • Support post-surgery: Confirm he has someone to assist post-op.
• Pre-op preparation:
  • Optimise comorbidities (BP control confirmed).
  • Consider pre-op blood tests or anaesthetic clearance if needed.

I would document his expectations and confirm informed consent.

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Q4: How would you manage Mr Thompson’s concerns regarding the surgery?

Answer:

• Acknowledge anxiety: Normal to feel apprehensive. Many patients feel this way.
• Provide information:
  • Surgery is quick (15-30 mins), minimally invasive, and done under local anaesthetic.
  • Post-op discomfort is usually mild.
• Reassure about outcomes:
  • Over 95% success rates in improving vision.
  • Rapid recovery (usually 24-48 hours for significant improvement).
• Discuss risks openly and how they’re minimised with modern techniques.
• Offer support:
  • Provide brochures.
  • Suggest speaking to someone who’s had surgery.
  • Offer follow-up to discuss further if he needs more time.

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Q5: What preventive measures and follow-up would you recommend post-surgery?

Answer:

• Post-operative care:
  • Topical antibiotics and steroids for 2-4 weeks.
  • Avoid rubbing the eye and strenuous activity.
  • Protective eye shield at night.
• Follow-up:
  • Review 1-2 days post-op, and at 4-6 weeks for new glasses prescription.
• Long-term prevention and eye health:
  • Wear sunglasses to protect against UV light.
  • Regular eye exams: every 1-2 years.
  • Manage chronic diseases (BP, lipids).
  • Smoking cessation (not applicable here).
  • Monitor for posterior capsular opacification (a common later complication).

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SUMMARY OF A COMPETENT ANSWER

• Accurate diagnosis of cataract with consideration of differentials.
• Clear explanation of cataract pathology and management in patient-friendly terms.
• Balanced discussion of surgical risks and benefits.
• Empathetic reassurance addressing anxiety about surgery.
• Detailed post-op care and preventive strategies to maintain eye health.

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PITFALLS

• Failing to assess impact on daily activities, particularly driving and independence.
• Overlooking differential diagnoses, like macular degeneration.
• Minimising surgical risks, leading to unrealistic expectations.
• Inadequate post-op instructions, risking complications.
• Ignoring emotional aspects, such as fear and anxiety about surgery.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Murtagh’s General Practice, 8th Edition
• Australian Society of Ophthalmologists on Cataract Surgery Information
• Vision Australia Cataract Resources

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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.

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