RACGP KFP 2017.2 Case 21 sees Betty, a 40 year old woman who presents with 4 weeks of cough, shortness of breath and marked reduction in her exercise tolerance, progressively getting worse, recently accompanied by fevers to 38C on a background of 20 pack year smoking history, drinks regularly, living in emergency accommodation with 15 other residents, recent IVDU. Chest Xray is performed

Describe the changes in this Xray. (list 2)

1. Right upper lobe consolidation
2. Floating heart sign
3. Hyperexpansion

NB – Hyperexpansion is assessed on a CXR via:

• Greater than 7 anterior ribs visible above the diaphragm in the mid-clavicular line AND/OR
• Flattening of the diaphragm

What are the risk factors for acquiring the disease in this presentation? (list 5)

1. Smoking history
2. Immunosuppression
3. Regular contact with children
4. Alcohol Abuse
5. Poor dental hygiene
6. IVDU

http://thorax.bmj.com/content/68/11/1057

Lifestyle factors associated with an increased risk of CAP included smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson’s disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.

https://www.ncbi.nlm.nih.gov/pubmed/24130229

Smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson’s disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.

https://www.ncbi.nlm.nih.gov/pubmed/10065680

An increased risk of CAP was associated with low body mass index, smoking, respiratory infection, previous pneumonia, chronic lung disease, lung tuberculosis, asthma, treated diabetes, chronic liver disease, and treatments with aminophiline, aerosols and plastic pear-spacers. In multivariate models, the only statistically significant risk factors were current smoking of >20 cigarettes x day.

What are the features of examination that signify severity in this presentation?

1. Altered mental state
2. Accessory muscle use
3. RR > 30
4. PR > 125
5. BP < 90/60
6. Shortness of breath
7. Temperature < 35 degrees C or >= 40 degrees C
8. O2 sats < 90%

O2 sats <90% (according to CURB) but <92% according to PSI

https://reference.medscape.com/calculator/pneumonia-severity-index-psi

From Murtaghs

• Altered mental state

• Rapidly deteriorating course

• Respiratory rate >30 per minute

• Pulse rate >125 per minute

• BP <90/60 mmHg

• Hypoxia Pa O2 <60 mm Hg or O2 saturation <90%

• Leucocytes <4 × 108 L or >20 × 109 /L

eTG

Red flags’ for community-acquired pneumonia in adults:

• respiratory rate higher than 30 breaths per minute
• systolic blood pressure lower than 90 mm Hg
• oxygen saturation lower than 92%
• acute onset confusion
• heart rate higher than 100 beats per minute
• multilobar involvement on chest X-ray.

RACGP Feedback – Case 21

This case focused on a middle-aged female patient with a short history of cough, shortness of breath and acute change in her exercise tolerance. Candidates were required to identify the specific consolidation on the chest X-ray and its location. In the KFP exam, the more specific an answer the more marks that are awarded.

In addition to identifying the abnormality, candidates were required to identify risk factors in the history that may predispose to the diagnosis, and then those factors signifying the severity of the presentation. In this case, the common errors were to repeat information in the scenario, make assumptions about the patient’s exposure to illnesses due to her name, and to provide symptoms when asked for examination findings.

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.