RACGP KFP 2017.2.12 – Back Pain in an Elderly Gent

by | Jan 10, 2018

Bill is a 75 year old patient who presents with worsening upper back pain for the past month, causing him both day and night pain.  He feels generally “off”.  Examination reveals localised spinal tenderness over the T10-T12 vertebrae. His past history includes prostate cancer, with previous prostatecomy. Medications include Goserelin 10.8 mg q3/12.

What are the most important differential diagnoses for this presentation? List 4

  1. Spinal metastases from previous prostate cancer
  2. Fractures secondary to osteoporosis
  3. Vertebral osteomyelitis
  4. Aortic aneursym

 

What pharmacological management options are there for pain in this patient? List 4

  1. Paracetamol 1g qid
  2. Nurofen 400mg tds
  3. Codeine 60mg qid prn
  4. Endep 10mg nocte

What are the components of planning for future care in the event an elderly patient is not able to make their own decision? (list 5)

  1. Appointing a medical power of attorney
  2. Creation of an Advanced Health Directive
  3. Creation of a Health Summary for the patient
  4. Establishing a MyHealthRecord
  5. ACAT assessment

References:

https://www.racgp.org.au/afp/2014/august/back-pain-in-a-cancer-patient/

https://www.medscape.com/viewarticle/712253_2

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395891/

 

 

RACGP Feedback – Case 12

This case focused on an older male patient with a previous history of prostate cancer, which was treated with prostatectomy and ongoing goserelin injections. The patient presents with a short history of low thoracic back pain and examination reveals localised spinal tenderness. Candidates were required to identify the possible differential diagnoses and options for pain management. This case identified the need to consider how answers are grouped when considering pain management.

Candidates who provided a list of different opiates or different NSAIDs did not score optimum marks. It is important to consider the range of management options and provide options from different drug classes. The final component of this case focused on planning for future care in the event the patient is not able to make his own decisions. Candidates successfully identified the need for advanced care planning and appointing a medical power of attorney. There are variations to the naming of these processes across the country; when this occurs in questions, marking takes account of differences across the states and territories.

RACGP Conclusion on Technique

As outlined above, there are some common themes and key issues to consider when approaching the KFP exam:

  • The KFP exam is not a simple short-answer paper. You must answer the question in the context of the clinical scenario provided, utilising all of the information provided. Read the scenario at least twice.
  • Keep your answers succinct.
  • Only provide the number of answers requested. Review your answer – have you created a list rather than one answer per line? If so, you will be penalised for extra answers.
  • Always read the question at least twice and, after you answer, check that you have answered the actual question asked.
  • Be specific in your answers, whether in the investigations being ordered or the treatment you are prescribing. Non-specific answers will not score or will attract a much lower score.
  • General answers such as ‘educate’, ‘refer’, ‘reassure’ or ‘review’ do not score without specific detail. For example, providing a review timeline and details about the specialist to whom you are referring (along with degree if urgency, if appropriate) may score marks if relevant to the scenario and question.
  • Be aware of clinical guidelines and any important changes or additions to treatments. If guidelines change very close to the exam, the marking keys are adapted to consider the original and the new guidelines so candidates are not penalised if they have not seen a guide published close to the exam sitting.
  • Access the practice exams provided after enrolment closes and utilise the RACGP assessment resources provided for candidates.

References

  1. https://tgldcdp.tg.org.au/viewTopic?topicfile=thoracic-spine-(upper-back)-pain&guidelineName=Rheumatology#toc_d1e788