CCE-CBD-218

EXAMINER ONLY INFORMATION

QUESTIONS

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

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

Q2. What are the implications of her Hepatitis B diagnosis in pregnancy, and how would you manage them?

• Prompt: Discuss risks of vertical transmission
• Prompt: Explain immunoprophylaxis for the baby
• Prompt: Discuss antiviral therapy options

Q3. What investigations and management would you recommend for Mei’s household contacts?

• Prompt: Screen husband and son for HBV serology
• Prompt: Provide vaccination if non-immune
• Prompt: Offer education on transmission prevention

Q4. How would you coordinate Mei’s ongoing care during pregnancy and postpartum?

• Prompt: Shared care with hepatology and obstetrics
• Prompt: Discuss delivery and breastfeeding considerations
• Prompt: Plan postnatal follow-up for both mother and baby

Q5. What preventive health measures would you recommend beyond Hepatitis B care?

• Prompt: Update Pap smear and cervical screening
• Prompt: Provide dietary and lifestyle advice for pregnancy
• Prompt: Address emotional wellbeing and support services

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Detailed Answer:

Approach:

• Greet Mei respectfully, ensuring a culturally sensitive and private environment.
• Acknowledge her anxiety and provide reassurance that this is a common diagnosis and can be effectively managed.

Explore Understanding of Diagnosis:

• Ask: “What do you know about Hepatitis B?”
• Clarify misconceptions (e.g., transmission methods, prognosis).

Identify Specific Concerns, Ideas, and Expectations:

• Explore what is worrying her most. For example:
  • Fear for her unborn child’s health.
  • Concerns about stigma within her family or community.
  • Worries about how this might affect her work or visa status.
• Ask about her expectations from the consultation today.

Explore Psychosocial Impact:

• Assess how this diagnosis is impacting her emotional wellbeing.
• Explore support systems—husband, family, friends.
• Offer mental health support if appropriate, such as counselling.

Culturally Sensitive Communication:

• Use plain language, avoid jargon.
• Offer a translator if needed.
• Provide written materials in her preferred language.

Reassurance and Education:

• Emphasise that:
  • Chronic Hepatitis B can often be managed with regular monitoring.
  • Transmission can be prevented through immunisation and other measures.
  • Her baby can be protected with timely immunoprophylaxis.

Relevant Guidelines:

• Australian National Hepatitis B Testing Policy.
• RACGP Guidelines for Preventive Activities in General Practice (Red Book).

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Q2: What are the implications of her Hepatitis B diagnosis in pregnancy, and how would you manage them?

Detailed Answer:

Risk of Vertical Transmission:

• Explain vertical transmission risk, especially with high viral load.
• Emphasise neonatal immunoprophylaxis as critical in prevention.

Immunoprophylaxis for Baby:

• Birth-dose Hepatitis B vaccine and Hepatitis B Immunoglobulin (HBIG) within 12 hours of birth.
• Complete vaccine series (4 doses in total).
• Post-vaccination serology at 9-12 months to confirm immunity and absence of infection.

Antiviral Therapy:

• Discuss with hepatologist/obstetrician the potential use of Tenofovir in the third trimester to reduce viral load if HBV DNA is >200,000 IU/mL (in this case, viral load is 10,000 IU/mL, so antivirals may not be required).

Breastfeeding:

• Safe if baby receives immunoprophylaxis at birth.

Coordination of Care:

• Shared antenatal care with midwife and obstetrician.
• Referral to hepatologist for ongoing monitoring.

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Q3: What investigations and management would you recommend for Mei’s household contacts?

Detailed Answer:

Screening:

• Test husband and son for:
  • HBsAg (active infection)
  • Anti-HBs (immunity)
  • Anti-HBc (previous exposure)

Management:

• If non-immune (Anti-HBs negative), offer Hepatitis B vaccination.
• If HBsAg positive, refer for further assessment and management.
• Educate on prevention: avoid sharing toothbrushes, razors, and encourage safe sexual practices (use of condoms if unsure of immunity status).

Household Education:

• Reassure them that casual contact (sharing meals, hugs) does not transmit Hepatitis B.
• Discuss the importance of regular follow-up for those infected.

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Q4: How would you coordinate Mei’s ongoing care during pregnancy and postpartum?

Detailed Answer:

Shared Care:

• GP, obstetrician, and hepatologist collaboration.
• Regular antenatal visits with attention to liver function tests.

Delivery and Breastfeeding Considerations:

• Vaginal delivery is safe; Caesarean not recommended solely for Hepatitis B.
• Encourage breastfeeding with timely neonatal immunisation.

Postnatal Follow-up:

• Check baby’s serology at 9-12 months (HBsAg and Anti-HBs).
• Continue Mei’s Hepatitis B monitoring post-pregnancy—regular ALT, HBV DNA, and surveillance for hepatocellular carcinoma (6-monthly liver ultrasound if at risk).

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Q5: What preventive health measures would you recommend beyond Hepatitis B care?

Detailed Answer:

Cervical Screening:

• Confirm status and offer screening (up to date 2 years ago).

Vaccinations:

• Ensure pertussis and influenza vaccines are given during pregnancy.
• COVID-19 vaccine if not yet received.

Lifestyle and Diet:

• Advise on healthy eating, adequate folic acid and iron intake.
• Encourage appropriate weight gain and physical activity (walking, swimming).

Mental Health and Social Support:

• Offer referral to a social worker or psychologist if distress persists.
• Link with community support groups, including culturally appropriate services.

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SUMMARY OF A COMPETENT ANSWER

• Explores Mei’s concerns with empathy and cultural sensitivity.
• Explains Hepatitis B transmission risks and preventive strategies clearly.
• Coordinates multidisciplinary antenatal care effectively.
• Recommends appropriate screening and management for household contacts.
• Addresses preventive health comprehensively, including cervical screening and vaccinations.

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PITFALLS

• Failing to explore psychosocial impact and emotional wellbeing.
• Overlooking the need for partner and household contact screening and vaccination.
• Not providing clear education about breastfeeding and vertical transmission risks.
• Neglecting to discuss postnatal care for mother and baby.
• Using complex medical terminology without ensuring understanding.

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REFERENCES

• RACGP Red Book (Preventive Activities in General Practice)
• Australian Immunisation Handbook
• National Hepatitis B Testing Policy
• ASID Perinatal Infections Guidelines 2014

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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 information about health and health determinants.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and tests diagnostic hypotheses, makes evidence-based decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Provides patient-centred management.

5. Preventive and Population Health

5.1 Provides care that anticipates and addresses health determinants.
5.2 Provides screening and intervention strategies.

6. Professionalism

6.1 Demonstrates ethical behaviour and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Uses quality and safety systems in practice.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical practice.

10. Identifying and Managing the Patient with Significant Illness

10.1 Provides appropriate management for patients with serious health needs.

11. Aboriginal Health Context (AH)

AH1.1 Provides care in the context of Aboriginal and Torres Strait Islander health.

12. Rural Health Context (RH)

RH1.1 Provides comprehensive care in rural communities.

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Competency at Fellowship Level

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

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