CCE-CBD-173

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you approach David’s concerns and gather relevant information?

• Prompt: Explore his understanding of his diagnosis
• Prompt: Identify specific concerns, ideas, and expectations
• Prompt: Explore psychosocial impact

Q2. What are the possible reasons for his symptoms, and how would you manage uncertainty?

• Prompt: Discuss differentials (TIA, MS, structural lesions)
• Prompt: Rationalise investigations or referrals
• Prompt: Explain uncertainty and safety-netting strategies

Q3. How would you manage David’s request for a referral and address his concerns about prior care?

• Prompt: Explain referral pathways and documentation
• Prompt: Manage medico-legal concerns empathetically and professionally
• Prompt: Provide clear follow-up plan

Q4. What additional preventive health measures should you offer David today?

• Prompt: Lifestyle advice (exercise, diet)
• Prompt: Address vaccination status (pneumococcal)
• Prompt: Cardiovascular risk management (smoking, lipids, BP)

THE COMPETENT CANDIDATE

The competent candidate should be able to:

---

Q1: How would you approach David’s concerns and gather relevant information?

Approach and Communication Style

• Start by building rapport with David, using open-ended questions and active listening to explore his ideas, concerns, and expectations (ICE framework).
• Acknowledge his anxiety and validate his experience with empathy: “I can understand why you’re feeling concerned after what you’ve been through.”

Information Gathering

• Ask about his symptoms timeline, including any progression or improvement since the episode of left-sided weakness.
• Clarify if he experienced any warning signs prior to the event (e.g., visual disturbance, headache).
• Explore associated symptoms: dizziness, slurred speech, visual field changes, limb clumsiness, sphincter disturbances (suggestive of MS), or headaches (tumour).
• Inquire about current functional status: balance issues, fatigue, and impact on daily activities.
• Explore psychosocial impact on quality of life, family relationships, and mental health (screen for depression/anxiety).
• Confirm understanding of his previous diagnosis and the information provided at discharge.
• Clarify expectations regarding the referral—does he want reassurance, definitive diagnosis, or a complaint process?

Communication of Plan

• Explain that you will help coordinate appropriate specialist referral and ensure continuity of care in the meantime.
• Reassure him about ongoing support from your practice.
• Provide safety-netting advice for red flag symptoms (sudden neurological changes, worsening balance, headache, incontinence).

---

Q2: What are the possible reasons for his symptoms, and how would you manage uncertainty?

Differential Diagnoses

• Transient Ischaemic Attack (TIA): most likely given the initial event, but absence of MRI leaves uncertainty.
• Multiple Sclerosis (MS): suggested by balance issues and cognitive symptoms, but no clear relapsing/remitting history.
• Structural Lesion (brain tumour): less likely, but considered given progressive cognitive symptoms.
• Vestibular Dysfunction or post-concussive syndrome: balance and fatigue may relate to this.
• Medication side effects (e.g., from statin or antihypertensive).

Managing Uncertainty

• Explain to David that his symptoms warrant further neurological assessment and imaging, which will clarify the diagnosis.
• Provide clear reasoning for the referral to neurology: MRI brain with contrast, possible lumbar puncture, and other tests.
• Emphasise the importance of a systematic approach rather than making assumptions from online information.
• Provide reassurance that delays in diagnosis are not uncommon, but you are addressing concerns promptly.
• Offer written information about TIA and MS, if appropriate, and recommend reliable sources like Healthdirect.

Safety-Netting and Follow-Up

• Provide instructions for urgent care if new symptoms occur.
• Book a follow-up appointment to review progress and specialist correspondence.

---

Q3: How would you manage David’s request for a referral and address his concerns about prior care?

Referral Process

• Confirm David’s preferred neurologist and explain that a GP referral letter will summarise his history, concerns, and current presentation.
• Include details of his past admission, investigation findings, and the rationale for referral.
• Discuss expected wait times and whether a private referral or telehealth might expedite assessment (considering rural context).

Addressing Concerns About Prior Care

• Empathise with his frustration: “It’s understandable to feel unsettled when things don’t seem clear.”
• Maintain professionalism; avoid criticising previous clinicians.
• Discuss options for addressing his concerns formally: feedback through the hospital’s patient liaison officer or via AHPRA if serious concerns arise.
• Reassure him that the focus now is on his health and ensuring the best care going forward.

Coordination of Care

• Discuss multidisciplinary involvement, such as physiotherapy for balance and occupational therapy for cognitive issues.
• Ensure shared care with his regular GP and chronic disease management, including diabetes and hypertension.

---

Q4: What additional preventive health measures should you offer David today?

Vaccination Review

• Discuss pneumococcal vaccine (due to diabetes and age >55) and ensure influenza and COVID-19 boosters are current.
• Consider shingles vaccine (Shingrix), as he is over 50.

Cardiovascular Risk Reduction

• Review BP and cholesterol targets: reinforce adherence to irbesartan, atorvastatin, and metformin.
• Consider intensifying management if needed (e.g., increasing irbesartan, checking HbA1c).
• Encourage lifestyle modifications:
  • Dietary advice: Mediterranean diet for cardiovascular and cognitive health.
  • Exercise: tailored program, supervised if balance issues persist.
  • Smoking and alcohol: reassure no issues.

Mental Health Support

• Offer a mental health care plan or referral to counselling/psychologist to address anxiety and adjustment issues.

Advance Care Planning

• Introduce the topic sensitively, especially if neurological diagnosis impacts long-term planning.

---

SUMMARY OF A COMPETENT ANSWER

• Effective exploration of patient’s ideas, concerns, and expectations (ICE)
• Differential diagnosis considering TIA, MS, structural lesions, etc.
• Clear management of diagnostic uncertainty and safety-netting
• Professional handling of referral and medico-legal concerns
• Preventive health measures, including vaccinations and cardiovascular risk management
• Coordination of multidisciplinary care, addressing rural health system limitations

---

PITFALLS

• Failure to explore and acknowledge patient concerns and expectations
• Overlooking possible differential diagnoses beyond TIA
• Providing premature reassurance without a clear plan
• Inadequate safety-netting for worsening neurological symptoms
• Criticising previous care rather than maintaining professionalism
• Neglecting preventive health opportunities (vaccinations, risk factor optimisation)

---

REFERENCES

• RACGP Red Book (9th Edition) on Preventive activities in general practice
• Australian Stroke Clinical Guidelines (2022)
• Healthdirect Australia on Reliable patient information
• Murtagh’s General Practice, 8th Edition (2022)
• National Immunisation Program Schedule

---

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 clinical data appropriately.
2.2 Selects and interprets appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises a differential diagnosis.
3.2 Demonstrates reasoning in clinical decision-making.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements evidence-based management plans.
4.2 Provides comprehensive patient education and counselling.

5. Preventive and Population Health

5.1 Provides care addressing prevention and early detection.
5.2 Provides care relevant to population health priorities.

6. Professionalism

6.1 Demonstrates ethical and professional behaviour.

7. General Practice Systems and Regulatory Requirements

7.1 Demonstrates appropriate referral and documentation.
7.2 Understands healthcare system navigation and resource allocation.

9. Managing Uncertainty

9.1 Manages diagnostic and therapeutic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients requiring urgent intervention.

12. Rural Health Context (RH)

RH1.1 Considers rural health system access and limitations.

Competency at Fellowship Level

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