CCE-CBD-175

EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: Explore Jonathan’s ideas about his symptoms (e.g., fear of strep throat)
• Prompt: Clarify his expectations regarding treatment (e.g., desire for antibiotics or rapid resolution)
• Prompt: Explore the impact on his work and wellbeing, including barriers to recovery (e.g., pain, fatigue)

Q2. What are the possible causes of Jonathan’s symptoms, and how would you manage uncertainty in this case?

• Prompt: Discuss differential diagnoses (e.g., Group A streptococcal pharyngitis, viral pharyngitis, infectious mononucleosis)
• Prompt: Rationalise investigation needs in a rural/remote setting (e.g., clinical diagnosis using Centor/McIsaac criteria vs. laboratory confirmation)
• Prompt: Explain uncertainty and safety-netting strategies, including red flags for complications (e.g., peritonsillar abscess, airway compromise)

Q3. What is your management plan for Jonathan today, and how would you address his concerns about returning to work?

• Prompt: Discuss symptomatic management (e.g., analgesia, hydration, rest)
• Prompt: Explain rationale for antibiotic prescribing (e.g., Centor score ≥3, delayed prescribing)
• Prompt: Advise on fitness for work, transmission prevention (e.g., stay home for 24 hours post-antibiotic commencement if streptococcal infection suspected)

Q4. What complications should you monitor for, and how would you manage them if they arise?

• Prompt: Identify serious complications (e.g., peritonsillar abscess, rheumatic fever, post-streptococcal glomerulonephritis)
• Prompt: Discuss referral criteria and emergency management (e.g., hospital referral for airway obstruction)
• Prompt: Outline follow-up, including review if symptoms persist or worsen

Q5. How might your approach differ if Jonathan were an Aboriginal or Torres Strait Islander patient living in a remote community?

• Prompt: Emphasise preventive strategies, including opportunistic health screening (e.g., cardiovascular, diabetes, skin health)
• Prompt: Discuss increased risk of acute rheumatic fever and need for more aggressive management
• Prompt: Highlight cultural considerations and community healthcare resources

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Answer:

I would start by establishing rapport with Jonathan and adopting a patient-centred approach. My aim would be to explore his concerns, ideas, expectations, and the impact of his throat symptoms on his daily life.

Information Gathering Approach:

• Open-ended questions: “Jonathan, can you tell me more about your throat symptoms?”
• Clarify details of symptoms: Onset, duration (how long he’s had the sore throat), severity, aggravating/relieving factors.
• Associated symptoms: Fever, difficulty swallowing, voice changes, cough, nasal congestion, fatigue, rash.
• Explore his ideas/concerns: “What are you most concerned this could be?” (e.g., worried about strep throat or cancer).
• Expectations: “What were you hoping we might do today?” (e.g., expectation for antibiotics or medical certificate).
• Impact on daily life: Assess impact on work (schoolteacher with voice strain), social activities, sleep, and appetite.

Psychosocial History:

• Explore stress, mental health, or recent exposures (crowded environments, family illnesses).
• Smoking and alcohol intake – as risk factors for more serious pathology.

Medical History:

• History of recurrent tonsillitis or glandular fever, previous antibiotic use, immunisation history (influenza, COVID-19), and chronic illnesses.

I would ensure empathy and active listening, maintaining clear and respectful communication to build trust. Using ICE (Ideas, Concerns, Expectations) framework is key.

Q2: What are the possible causes of Jonathan’s symptoms, and how would you manage uncertainty in this case?

Answer:

The differential diagnoses for a sore throat include:

• Viral pharyngitis (most common)
• Group A beta-haemolytic streptococcal (GABHS) pharyngitis
• Infectious mononucleosis (EBV)
• Peritonsillar abscess (quinsy) (complication)
• Epiglottitis (rare but serious)
• Gonococcal pharyngitis (sexual history relevant)

Managing Uncertainty:

• Apply the Centor/McIsaac criteria to assess the likelihood of GABHS pharyngitis (fever, absence of cough, tonsillar exudate, tender anterior cervical nodes, age).
• Consider rapid antigen detection testing (RADT) or throat culture, though not routinely recommended in Australia unless diagnostic uncertainty remains high.
• Discuss safety netting clearly: outline when to return or seek urgent care (e.g., difficulty breathing, worsening pain, drooling).
• Explore the possibility of atypical infections (HIV seroconversion, gonorrhoea) if history supports.
• Rationalise the use of antibiotics based on clinical scoring systems and explain this to the patient.

Q3: What is your management plan for Jonathan today, and how would you address his concerns about returning to work?

Answer:

Management Plan:

• Symptomatic relief: Paracetamol/ibuprofen for pain and fever, maintain hydration, rest.
• Antibiotics: If Centor score ≥3, consider a 10-day course of phenoxymethylpenicillin. For penicillin allergy, azithromycin or cephalexin.
• Voice care advice: Minimise talking, humidified air, and avoid irritants (smoking).
• Medical certificate: Provide time off work if febrile or symptomatic, typically for 24-48 hours after starting antibiotics if bacterial.
• Infectious control advice: Hand hygiene, avoid sharing utensils, stay away from work if febrile.

Education:

• Explain the natural history of viral illness vs. bacterial.
• Explain rationale for not prescribing antibiotics if not indicated.
• Provide reassurance about recovery expectations (5-7 days).

Q4: What complications should you monitor for, and how would you manage them if they arise?

Answer:

Potential complications include:

• Peritonsillar abscess (quinsy): Severe unilateral throat pain, trismus, uvula deviation. Urgent ENT referral or emergency management.
• Rheumatic fever/post-streptococcal glomerulonephritis: More common in Aboriginal communities. Requires early recognition, management, and follow-up.
• Airway compromise (epiglottitis): Stridor, drooling—emergency.
• Otitis media/sinusitis/retropharyngeal abscess.

Management:

• Educate Jonathan on warning signs.
• Arrange follow-up review within 48-72 hours if symptoms worsen.
• Escalate care via ED or ENT as necessary.

Q5: How might your approach differ if Jonathan were an Aboriginal or Torres Strait Islander patient living in a remote community?

Answer:

• Increased risk of acute rheumatic fever and rheumatic heart disease; thus, a lower threshold for antibiotics.
• Culturally appropriate communication and ensuring involvement of Aboriginal health workers.
• Access to healthcare: Ensure follow-up and continuity of care.
• Preventive health: Opportunistic screening for chronic disease, vaccinations (influenza, pneumococcus), skin checks, and smoking cessation.

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SUMMARY OF A COMPETENT ANSWER

• Structured history-taking using ICE and psychosocial context.
• Clear reasoning for differential diagnoses and management.
• Appropriate use of guidelines like Centor criteria.
• Empathetic communication with education on natural history and safety netting.
• Consideration of ATSI health priorities in management.

PITFALLS

• Failing to address patient concerns or expectations.
• Overprescribing antibiotics without clear indication.
• Not recognising red flags for complications.
• Inadequate safety netting or follow-up planning.
• Overlooking cultural factors in Aboriginal health.

REFERENCES

• Therapeutic Guidelines on Antibiotic
• RACGP Guidelines on Red Book
• Australian Commission on Safety and Quality in Health Care on Antimicrobial Stewardship

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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 relevant and accurate information.
2.2 Organises and structures information effectively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates hypotheses and discriminates effectively between diagnoses.
3.2 Demonstrates clinical reasoning and justifies decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops evidence-based management plans.
4.2 Engages patients in shared decision-making.

5. Preventive and Population Health

5.1 Provides appropriate preventive care in the consultation.
5.2 Considers social determinants and community health factors.

6. Professionalism

6.1 Demonstrates ethical behaviour and integrity.
6.2 Displays respect and cultural sensitivity.

9. Managing Uncertainty

9.1 Recognises and manages uncertainty appropriately.
9.2 Provides safety netting and appropriate follow-up.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises serious illness and provides timely management.

11. Aboriginal Health Context (AH)

AH1.1 Applies knowledge of Aboriginal and Torres Strait Islander health needs.
AH1.2 Provides culturally appropriate care.

Competency at Fellowship Level

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