RACGP KFP 2017.2.19 – Acute Disturbance in Intellectual Disabillity

by | Jan 9, 2018

In Case 19 of the 2017.2 KFP, you attend a home visit of Bill, a 19 year old disability resident with a history of Prader-Willi Syndrome who staff are concerned has been acutely disturbed recently over a period of 3 days, becoming abusive to the staff, talking about Jesus and pouring water on other residents, when he is normally quite lucid and pleasant. The patient is on no medications.

What methods could you employ in obtaining history in Bill? (list 5)

  1. Interviewing Bill
  2. Interviewing staff
  3. Interviewing family
  4. Observing behaviour directly
  5. Review case worker notes over past week

What are the differentials of this presentation? (list 8)

  1. Urinary tract infection
  2. Pneumonia
  3. Encephalitis
  4. Cerebrovascular accidents, such as cerebral infarction
  5. Nutrient deficiencies – b12
  6. Hypoglycaemia
  7. Acute psychosis
  8. Sleep deprivation
  9. Faecal retention

 

 

What are the most appropriate initial investigations to request? (list 5)

  1. CXR
  2. Urine MCS
  3. FBC
  4. BSL
  5. CT head

 

From https://www.racgp.org.au/your-practice/guidelines/silverbook/common-clinical-conditions/dementia/

Investigations are usually undertaken to identify reversible causes of dementia and may include:

  • haemoglobin, white cell count, erythrocyte sedimentation rate, serum B12 and folate levels
  • serum electrolytes and renal function, serum calcium and phosphate
  • liver function, thyroid function, blood sugar
  • urine micro and culture
  • chest X-ray (if delirium)
  • brain scan
  • syphilis serology and HIV antibodies if indicated.

 

RACGP Feedback – Case 19

This case focused on a vulnerable adult with intellectual disability and who is a resident in a community group home presenting with recent behavioural changes. The questions assessed candidates’ ability to identify sources to corroborate the history, possible differential diagnoses for the presentation and selection of initial investigations.

A common error was to assume that, given the patient had intellectual disability, she would have mental health issues and would therefore require a mental health care team to assist in history. Many candidates did not seek to ask the patient herself. While she may have minimal verbal communication, this is not a reason not to approach the patient. In providing differential diagnoses, it was a common error to enquire about information already provided in the scenario.

For example, asking about medication side effects or interactions when the scenario stated that patient is on no medications, or enquiring about hearing aid problems when there is no mention of hearing difficulties in the scenario. Candidates should utilise the information in the scenario and not create and then solve problems that are not listed.

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.