In Case 15 of RACGP KFP 2017.2 you meet Billy, a 3 year old child who presented earlier today to your rural country practice with URTI symptoms, but is now brought in by Mum with refusal to feed, sitting still, drooling and fevers. You note that he is sitting still, not turning head throughout the consult, and looks toxic.

What are the most important differentials to consider in this patient? (List 1)

1. Acute epiglottitis

What features of examination are the most important to elicit? (List 7)

1. Mental state alertness
2. Oxygen saturations
3. Cyanosis
4. Respiratory distress e.g. accessory muscle use
5. Stridor
6. Central Refill Time < 2 sec
7. Auscultation – wheeze

 

What are your immediate management considerations when approaching this child? (List 2)

1. Immediate transfer to appropriate specialist centre for securing of airway
2. Prepare equipment for acute cardiac arrest

Avoid procedures that might increase the child’s anxiety, until after the child’s airway is secured. Procedures such as venipuncture and intravenous access, although appropriate in some cases involving children with acute epiglottitis, may heighten anxiety and precipitate airway compromise.

Never place a child with epiglottitis in a supine position (other than during the endotracheal intubation procedure)

 

References:

https://emedicine.medscape.com/article/963773-overview

https://www.racgp.org.au/afp/2010/may/assessment-of-the-unwell-child/

https://www.aafp.org/afp/2001/1001/p1219.html

 

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RACGP Feedback – Case 15

This case featured a child who initially had minor upper-respiratory symptoms then deteriorated rapidly with clinical features suggestive of evolving epiglottitis. Candidates were required to identify possible differential diagnoses, examination features that would identify a seriously unwell child, and the immediate management of that child. In assessing and managing the child, the most serious diagnosis of epiglottis must always be considered.

Therefore, anything that may distress the child and put the airway at risk during examination, such as examining the throat, caused the candidate to score zero for that question, but not the whole case. It is reassuring that the vast majority of candidates identified epiglottitis as a possible differential diagnosis and did not attempt to assess the airway. The KFP exam may contain questions where answers are possibly considered dangerous, and such answers will result in a candidate score of zero for that question.

When providing differential diagnoses, it is important to provide specific diagnoses rather than a list of causative organisms given that they may cause a range of symptoms or diagnoses. The KFP exam is assessing management in the context of a general practice environment. As such, when providing immediate management it is important to ensure that answers are contextualised for general practice.

In this case, many of the answers provided appeared to be emergency-department-focused, such as attempting to obtain intravenous access. The other common errors were not providing immediate management and failure to recognise the urgency of the situation; answers relating to reassuring the mother or educating about epiglottitis, or arranging follow-up. While these are important aspects, they did not address key elements of immediate management in general practice and thus did not properly address the question.

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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.