CCE-CBD-201

EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: How do you differentiate measles from other childhood viral exanthems?
• Prompt: What clinical features are characteristic of measles?

Q2. What are your initial management steps?

• Prompt: How do you manage a child with suspected measles?
• Prompt: What public health measures are necessary?

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

• Prompt: How would you discuss the implications of measles and its potential complications?
• Prompt: How would you address vaccine hesitancy in a respectful manner?

Q4. What preventive measures can help reduce the spread of measles in the community?

• Prompt: What is the role of post-exposure prophylaxis?
• Prompt: How do you counsel parents on the benefits of childhood immunisation?

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

• Prompt: What complications of measles require escalation of care?
• Prompt: How would you manage respiratory distress in a child with measles?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Answer:

Fever with cough, conjunctivitis, and rash in an unvaccinated child raises concern for a vaccine-preventable illness.

Differential Diagnoses:

1. Measles (Most Likely Diagnosis)
   • Key features: Fever, cough, conjunctivitis, Koplik spots, maculopapular rash starting on the face.
   • Highly contagious, requires urgent public health notification.
2. Rubella (German Measles)
   • Key features: Milder illness, pink rash, posterior cervical lymphadenopathy.
   • Less severe than measles.
3. Scarlet Fever (Group A Strep)
   • Key features: Sandpaper rash, strawberry tongue, pharyngitis.
   • Caused by streptococcal infection, treatable with antibiotics.
4. Roseola Infantum (HHV-6 Infection)
   • Key features: High fever for 3 days, then rash appears after fever subsides.
5. Kawasaki Disease (Less Likely Here)
   • Key features: Prolonged fever >5 days, conjunctivitis, strawberry tongue, extremity desquamation.
   • Requires urgent evaluation due to risk of coronary aneurysms.

Most Likely Diagnosis:

• Measles, given the unvaccinated status, Koplik spots, and characteristic rash.
• Urgent confirmation with PCR and public health notification.

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Q2: What are your initial management steps?

Answer:

1. Supportive Management

• Isolate patient immediately (highly contagious via respiratory droplets).
• Ensure hydration, manage fever with paracetamol.

2. Confirm Diagnosis with Investigations

• Measles PCR from nasopharyngeal swab.
• Serology: Measles IgM and IgG.
• FBC, UECs, CRP – Assess severity.

3. Public Health Notification & Contact Tracing

• Notify the local public health unit (mandatory).
• Advise contacts to check immunisation status.
• Post-exposure prophylaxis (MMR vaccine or IVIG) for at-risk individuals.

4. Follow-Up & Monitoring

• Daily monitoring for complications (pneumonia, encephalitis).
• Review in 48 hours to ensure recovery.

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

Answer:

Diagnosis Explanation:

• “James has measles, a serious but preventable infection.”
• “Measles spreads easily through coughing, sneezing, or touching contaminated surfaces.”

Treatment Plan:

• “There is no specific treatment, but we will manage symptoms with fluids, fever control, and rest.”
• “We need to isolate him for at least 4 days after rash onset to prevent spread.”

Addressing Vaccine Hesitancy:

• “Vaccination prevents serious complications like pneumonia and brain inflammation.”
• “Would you like more information about the MMR vaccine’s safety and effectiveness?”

Safety-Netting:

• “If James develops breathing difficulties, confusion, persistent fever, or seizures, seek urgent care.“
• “We will check in 48 hours and follow up after recovery to discuss vaccination.”

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Q4: What preventive measures can help reduce the spread of measles in the community?

Answer:

• Immediate isolation of suspected cases.
• Post-exposure prophylaxis:
  • MMR vaccine within 72 hours for contacts without prior immunity.
  • IVIG for immunocompromised individuals or infants <6 months old.
• Encourage childhood vaccination:
  • MMR at 12 months and 18 months (as per Australian schedule).
  • Boosters in adults without documented immunity.
• Public education:
  • Community awareness of measles symptoms and risks.

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

Answer:

• Severe respiratory distress (pneumonia, bronchiolitis).
• Neurological symptoms (encephalitis, seizures).
• Persistent high fever >5 days.
• Severe dehydration (poor oral intake, lethargy).

Emergency Management of Complications:

• Admit if respiratory or neurological complications develop.
• IV fluids, oxygen therapy, empirical antibiotics if secondary bacterial infection suspected.
• High-dose Vitamin A for severe cases (reduces morbidity).

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SUMMARY OF A COMPETENT ANSWER

• Identifies measles as the most likely diagnosis based on clinical features and vaccination status.
• Implements immediate infection control measures and public health notification.
• Provides supportive care while monitoring for complications.
• Educates parents on vaccine-preventable diseases and addresses hesitancy.
• Recognises red flags requiring hospital referral.

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PITFALLS

• Failing to consider measles in an unvaccinated child.
• Delaying public health notification and contact tracing.
• Not recognising red flags for severe complications.
• Providing antibiotics in a clear viral illness.
• Not addressing parental concerns regarding immunisation.

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REFERENCES

• National Centre for Immunisation Research and Surveillance (NCIRS) on Measles Factsheet
• Australian Immunisation Handbook (ATAGI) on Vaccine Safety Information
• RACGP Guidelines for Managing Vaccine-Preventable Diseases in General Practice

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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 Engages the parents to gather information about the child’s symptoms, concerns, and expectations.
1.2 Provides clear information on childhood infectious diseases and vaccine-preventable illnesses.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to childhood infections, including exposure risks and immunisation status.
2.2 Identifies red flag symptoms requiring urgent assessment.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common childhood viral and bacterial infections.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including symptomatic and supportive care.
4.2 Recognises when hospital referral or public health notification is required.

5. Preventive and Population Health

5.1 Provides education on childhood vaccination and herd immunity.

Competency at Fellowship Level

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