EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key elements in taking a history from this patient?

• Prompt: Focus on the patient’s symptoms, mental health history, substance use, and psychosocial factors.

Q2. What is your differential diagnosis for this patient?

• Prompt: Consider PTSD, alcohol use disorder, depression, anxiety, and other psychiatric conditions.

Q3. Outline your management plan for John.

• Prompt: Address both the PTSD and comorbid conditions like alcohol use and consider referrals.

Q4. How would you discuss PTSD and its management with the patient?

• Prompt: Consider the need for psychoeducation, therapeutic options, and engagement strategies.

Q5. What are the risks and benefits of different therapeutic interventions for PTSD?

• Prompt: Compare pharmacological vs non-pharmacological treatments, consider patient preferences and potential side effects.

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THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the key elements in taking a history from this patient?

A competent candidate will begin by establishing a rapport with John, using empathetic and non-judgmental communication. This is crucial to making the patient feel safe and comfortable, given the sensitive nature of his symptoms related to PTSD.

Key elements to cover in the history include:

• Symptoms of PTSD: Ask about the frequency, severity, and triggers for his nightmares, flashbacks, hypervigilance, and avoidance behaviours. Clarify how these symptoms impact his daily life, including work, social activities, and relationships.
• Mental Health History: Explore past mental health issues, including previous diagnoses of depression, and any treatments or therapies received. Determine if there have been any recent changes or escalation in symptoms.
• Substance Use: Detailed inquiry into his alcohol consumption, including the amount, frequency, and any negative impacts (e.g., on sleep, mood, or functioning). Screen for other substances, such as illicit drugs or misuse of prescription medication.
• Psychosocial Factors: Explore his social support network, relationships, employment challenges, financial stress, and any legal or social concerns. Ask about coping strategies and whether he feels at risk of self-harm or harm to others.
• Physical Symptoms: Review his recent headaches, sleep disturbances, and other somatic complaints. Screen for symptoms that might suggest other mental health disorders, such as anxiety or mood disorders.
• Military Experience: Gather details about his deployment to Afghanistan, particularly any specific traumatic events or stressors that might contribute to PTSD symptoms.

Throughout the history-taking, use open-ended questions to encourage detailed responses, actively listen, and show empathy to build trust. Tailor questions based on responses and remain alert to cues indicating distress or reluctance to disclose sensitive information.

Q2: What is your differential diagnosis for this patient?

A competent candidate should present a differential diagnosis that considers both psychological and medical conditions:

• Post-Traumatic Stress Disorder (PTSD): The primary consideration given John’s history of trauma exposure, nightmares, flashbacks, hypervigilance, and avoidance behaviours.
• Major Depressive Disorder (MDD): Symptoms like irritability, poor concentration, and feelings of disconnection may overlap with depression.
• Alcohol Use Disorder: Given his high alcohol consumption, consider this as a comorbid condition or a primary diagnosis contributing to mood and sleep disturbances.
• Generalized Anxiety Disorder (GAD): Symptoms such as restlessness, fatigue, difficulty concentrating, and muscle tension could align with GAD.
• Adjustment Disorder: Consider if the symptoms are a reaction to his recent life transition from military service to civilian life.
• Sleep Disorder: Evaluate for primary or secondary insomnia due to PTSD or alcohol use.
• Traumatic Brain Injury (TBI): Given his military history, consider this if there are any neurological symptoms like memory loss or concentration difficulties.
• Organic: intracerebral, metabolic, endocrine, drug-induced

Highlight that PTSD is the leading diagnosis, but other comorbidities or differentials should not be overlooked. Justify each diagnosis based on clinical findings and history.

Q3: Outline your management plan for John.

A competent candidate should formulate a management plan that addresses both immediate and long-term needs:

1. Immediate Safety and Risk Assessment:
   • Conduct a thorough risk assessment for suicide, self-harm, or harm to others.
   • Discuss options for urgent mental health support, including referral to a psychologist or psychiatrist and involving crisis teams if needed.
2. Non-Pharmacological Interventions:
   • Recommend evidence-based psychological therapies, such as trauma-focused Cognitive Behavioural Therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR).
   • Discuss alcohol reduction strategies, provide information on local addiction support services, and consider referral for specialist addiction services.
3. Pharmacological Management:
   • Consider starting selective serotonin reuptake inhibitors (SSRIs), like sertraline or paroxetine, which are first-line pharmacological treatments for PTSD.
   • Evaluate the need for adjunct medications, such as prazosin for nightmares, or consider a short-term prescription of sleep aids if indicated, with caution.
4. Follow-up and Ongoing Monitoring:
   • Schedule regular follow-ups to assess treatment response, medication adherence, and monitor for side effects or deterioration.
   • Develop a safety plan, including a list of emergency contacts and services.
5. Referral and Collaboration:
   • Coordinate with mental health services, social workers, and veteran support organizations for holistic care.
   • Consider referral to a psychiatrist for medication management or complex PTSD cases.

Q4: How would you discuss PTSD and its management with the patient?

A competent candidate should aim for clear, empathetic communication to explain PTSD:

1. Explain the Diagnosis:
   • Describe PTSD as a common and treatable condition resulting from trauma. Use simple language to explain how John’s experiences in Afghanistan may have triggered his symptoms.
   • Emphasize that his symptoms, such as nightmares, flashbacks, and avoidance, are normal responses to abnormal events.
2. Outline the Management Plan:
   • Discuss both non-pharmacological (e.g., CBT, EMDR) and pharmacological options (e.g., SSRIs).
   • Emphasize the importance of gradual engagement with therapy and setting realistic goals.
3. Address Concerns and Encourage Participation:
   • Address potential fears or misconceptions about mental health treatment, including concerns about medication or therapy.
   • Encourage John to view treatment as a collaborative process, where his input and comfort with different treatment options are valued.
4. Provide Written and Verbal Resources:
   • Provide pamphlets or websites with information about PTSD and its management, including local support groups and services for veterans.

Q5: What are the risks and benefits of different therapeutic interventions for PTSD?

A competent candidate should compare therapeutic interventions:

• Psychological Interventions:
  • Benefits: Effective for long-term management, no pharmacological side effects, builds coping skills.
  • Risks: Initial worsening of symptoms during exposure therapy requires regular attendance and engagement.
• Pharmacological Interventions (SSRIs):
  • Benefits: It may reduce symptoms such as anxiety and depression and improve sleep.
  • Risks: Side effects (e.g., nausea, weight gain, sexual dysfunction), risk of withdrawal symptoms, especially in irregular takers.
• Combined Approach:
  • Benefits: Potentially greater symptom reduction by addressing both physiological and psychological aspects.
  • Risks: Increased complexity in managing side effects and adherence.
• Alternative Interventions (e.g., prazosin for nightmares):
  • Benefits: Targeted symptom relief.
  • Risks: Limited evidence, potential side effects like hypotension.

SUMMARY OF A COMPETENT ANSWER

• Establishes rapport and demonstrates empathy.
• Comprehensive history covering PTSD, mental health, and social factors.
• Differential diagnoses include PTSD, comorbidities, and other psychiatric conditions.
• Clear management plan with immediate and long-term strategies.
• Effective communication with the patient, addressing concerns and providing resources.

PITFALLS

• Failing to explore all relevant psychosocial and trauma history.
• Overlooking comorbid conditions such as alcohol use or depression.
• Inadequate risk assessment for self-harm or harm to others.
• Lack of clarity when explaining treatment options and their side effects.
• Neglecting follow-up and ongoing monitoring.

REFERENCES

• Australian Guidelines for the Treatment of Acute Stress Disorder and PTSD: Phoenix Australia
• RACGP Guidelines for Alcohol Use: RACGP

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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 A comprehensive biopsychosocial history is taken from the patient.
2.2 The results of investigations are interpreted in the context of the patient.

3. Diagnosis, Decision-Making and Reasoning

3.1 Integrates and synthesises knowledge to make decisions in complex clinical situations.
3.4 Collects/reports clinical information in a hypothesis-driven manner.

4. Clinical Management and Therapeutic Reasoning

4.2 Outlines and justifies therapeutic options selected based on the patient’s needs.
4.5 Develops a patient-centred and comprehensive management plan.

5. Preventive and Population Health

5.1 Implements strategies for primary prevention and early detection of disease.

6. Professionalism

6.1 Exhibits high standards of moral and ethical behaviour towards patients and colleagues.

7. General Practice Systems and Regulatory Requirements

7.1 Maintains comprehensive and accurate clinical records and manages patient confidentiality appropriately.

8. Procedural Skills

8.1 Refers appropriately when a procedure is outside their level of competence.

9. Managing Uncertainty

9.1 Manages the uncertainty of ongoing undifferentiated conditions.

10. Identifying and Managing the Patient with Significant Illness

10.1 A patient with significant illness is identified and managed appropriately.

Competency at Fellowship Level

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