CCE-CBD-197

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate SLE from rheumatoid arthritis and other connective tissue diseases?
• Prompt: What features would raise suspicion for lupus?

Q2. What are your initial management steps?

• Prompt: What investigations are required at this stage?
• Prompt: When would you refer for rheumatology review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address her concerns about lupus?
• Prompt: What is the role of medications and lifestyle modifications?

Q4. What preventive measures can help manage her symptoms and long-term health?

• Prompt: What lifestyle changes should she implement?
• Prompt: When should she seek further medical attention?

Q5. What are the red flags that would necessitate urgent referral or intervention?

• Prompt: What clinical features suggest a severe lupus flare?
• Prompt: How would you manage lupus nephritis or CNS involvement?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease with multisystem involvement.

Differential Diagnoses:

1. Systemic Lupus Erythematosus (Most Likely Diagnosis)
   • Key features: Fatigue, malar rash, polyarthritis, photosensitivity, and hair thinning.
   • Family history of SLE.
   • Requires autoimmune serology (ANA, dsDNA, complement levels).
2. Rheumatoid Arthritis (RA)
   • Key features: Polyarthritis with morning stiffness, but usually no rash or photosensitivity.
   • RF and anti-CCP antibodies would be positive.
3. Dermatomyositis
   • Key features: Proximal muscle weakness, heliotrope rash, Gottron’s papules.
   • Check CK, aldolase, anti-Mi2 antibodies.
4. Mixed Connective Tissue Disease (MCTD)
   • Features of SLE, RA, and scleroderma overlap.
   • Anti-U1 RNP antibodies positive.
5. Sjogren’s Syndrome
   • Key features: Dry eyes, dry mouth, arthralgia.
   • Anti-Ro/La antibodies positive.

Most Likely Diagnosis:

• SLE, based on malar rash, polyarthritis, fatigue, photosensitivity, and family history.
• Requires ANA, dsDNA, and complement levels for confirmation.

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Q2: What are your initial management steps?

Answer:

1. Confirm Diagnosis with Investigations

• Autoimmune panel:
  • ANA (high sensitivity for SLE).
  • Anti-dsDNA, Anti-Smith (specific for SLE).
  • Complement levels (C3/C4) – low in active disease.
• Inflammatory markers:
  • ESR (often elevated), CRP (may be normal).
• Renal function tests:
  • Urine protein/creatinine ratio to assess nephritis.

2. Initial Treatment

• NSAIDs for joint pain.
• Hydroxychloroquine – cornerstone for mild lupus.
• Corticosteroids – for severe flare-ups.

3. Referral and Follow-Up

• Rheumatology referral for diagnosis confirmation and long-term management.
• Monitor every 3-6 months for organ involvement.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms are suggestive of systemic lupus erythematosus (SLE), an autoimmune condition where the immune system attacks healthy tissues.”
• “We will confirm this with blood tests and refer you to a specialist.“

Treatment Plan:

• “We will start hydroxychloroquine, which helps control symptoms and prevent flares.”
• “Steroids may be used if symptoms worsen.”

Safety-Netting:

• “If you develop severe fatigue, kidney issues, or neurological symptoms, seek urgent medical help.“
• “We will review you in 4 weeks with your test results.”

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Q4: What preventive measures can help manage her symptoms and long-term health?

Answer:

• Sun protection – UV light can trigger flares.
• Regular exercise and rest to manage fatigue.
• Avoid smoking and alcohol – worsens symptoms.
• Yearly vaccinations – Flu, pneumococcus, HPV.
• Monitor for early signs of lupus nephritis.

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Q5: What are the red flags that would necessitate urgent referral or intervention?

Answer:

• Severe renal involvement (proteinuria, haematuria, rising creatinine).
• Neurological symptoms (seizures, psychosis, stroke-like episodes).
• Severe vasculitis (skin ulcers, gangrene, digital infarcts).
• Uncontrolled hypertension or heart involvement (pericarditis, myocarditis).

Emergency Management of a Severe Lupus Flare:

• Urgent rheumatology assessment.
• IV corticosteroids or immunosuppressants (e.g., cyclophosphamide).

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SUMMARY OF A COMPETENT ANSWER

• Correctly differentiates SLE from other autoimmune conditions.
• Orders ANA, dsDNA, complement, and urine PCR for diagnosis.
• Initiates hydroxychloroquine and NSAIDs.
• Recognises red flags requiring urgent referral.
• Provides lifestyle advice and long-term monitoring.

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PITFALLS

• Failing to recognise early SLE symptoms.
• Not ordering autoimmune serology or urine PCR.
• Overlooking nephritis or neurological involvement.
• Delaying referral to rheumatology.

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REFERENCES

• RACGP Guidelines – Autoimmune Disease Management
• GP Exams – SLE (Systemic Lupus Erythematosus)

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to autoimmune diseases.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between systemic lupus erythematosus (SLE) and other autoimmune or inflammatory conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including pharmacological and non-pharmacological interventions.
4.2 Recognises when urgent investigations or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on lifestyle modifications, sun protection, and medication adherence.

Competency at Fellowship Level

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