Bob is a 15 year old boy who was brought in by Ambulance to your rural practice after being observed at school lunchtime to have lost consciousness, fallen to the ground and had some muscle jerking which lasted for about 5 minutes. They are unsure about any further detailed history. He is not on any medication and has no significant medical history.

What are the most important differentials for this presentation? List 8

1. Generalised epilepsy
2. Hypoglycaemia
3. Hypotension due to dehydration
4. Hyponatraema
5. Cardiac arrhythmia
6. Recreational drug use
7. Meningitis
8. Head trauma
9. Hypertrophic cardiomyopathy
10. Cerebrovascular accident (CVA) e.g. subarachnoid haemorrhage

note the question is most important, not most likely.  Likely causes would be dehydration (both important and common), vasovagal syncope, orthostatic hypotension  etc

This was derived from the context of the lists of faints, fits and funny turns and applying that to a 15 year old. The references below describe some lists and there is a child specific causes of collapse in table 96.2 of Murtaghs 6th edition which is also handy.

The important point from the RACGP feedback listed below is to apply broad differentials in this case.

What are the key features of history that would assist in formulating a diagnosis? (List 12)

1. Chest pain immediately prior
2. Shortness of breath immediately prior
3. Headache
4. Palpitations
5. Food intake that day
6. Water intake that day
7. Recreational drug use
8. Micturition during seizure
9. Tongue biting during seizure
10. Post ictal confusion
11. Family history of epilepsy
12. Family history of cardiac disorders
13. Neurological weakness
14. Neurological sensation changes
15. Fever
16. Head trauma

I think this question is aiming at differentiating epilepsy from other causes while also remaining broad. There is good broad information in Ch 54 of Murtagh’s 6th Edition and the answers to this question would have flowed from your differentials at the beginning.

 

Further reading:

https://www.racgp.org.au/afp/2014/march/epilepsy/

 

RACGP Feedback – Case 26

The final case featured an adolescent male patient who collapses while having lunch at school. There was observed loss of consciousness and some associated muscle/limb jerking. Candidates were required to use the information given to identify the possible diagnoses in a patient presenting with fits, faints or dizzy spells.

Quality answers looked at the range of presentations possible rather than just neurological presentations, and considered causes such as cardiovascular, metabolic psychological and possible substance misuse.

The most common error was to list different forms of epilepsy and not consider a broader range of possibilities. The second question in the case required candidates to identify key features in a history with this presentation that assist in establishing a diagnosis.

Candidates needed to appreciate the range of possible causes and their underlying distinctive clinical features to elicit in the patient’s history. Had the candidate focused solely upon different forms of epilepsy in the first question, and thus only focused upon on a neurological history in the second question, this would not have provided optimum marks.

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.

GPCC Feedback

This question asks candidates to think broadly about causes of syncope in adolescence, in context of the vignette discussed.

I think if you understood that you should remain broad when its (seemingly) obvious that you should, and go specific when requested, as two separate approaches to the exam questions, you would have done well.

Most of the trap in this question is not going to specific when they want you to go broad.

Understanding HEADSS and applying that onto every question about adolescent medicine is probably also high yield.

 

References/Further Reading

1. http://oxfordmedicine.com/view/10.1093/med/9780199608997.001.0001/med-9780199608997-chapter-29
2. https://www.ncbi.nlm.nih.gov/pubmed/16333481
3. http://www.stanfordchildrens.org/en/topic/default?id=seizures-and-epilepsy-in-children-90-P02621
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805591/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2065949/
6. Table 96.2 of Murtaghs 6th edition
7. Ch 54 of Murtaghs 6th Edition
8. https://www.rch.org.au/clinicalguide/guideline_index/Engaging_with_and_assessing_the_adolescent_patient/