In this case candidates are asked to provide differentials and investigations on a moderately differentiated case of progressive light-headedness, near-syncope attacks and reduced exercise tolerance, and weight loss.
Bill is a 70 year old man with a history of hypertension who presents with 4 weeks of progressive light-headedness, near-syncope attacks and reduced exercise tolerance, as well as 10kg in weight loss in the last 2 months and sweating profusely at night and altered bowel habit. He has nil other symptoms.
What are the differential diagnoses for this presentation? List 8
- Ischaemic heart disease
- Iatrogenic/medication caused hypotension
- Decompensated congestive heart failure
- Decompensated aortic stenosis
- Leaukaemia
- Colorectal cancer with metastasis
- Carotid artery stenosis
- Atrial Fibrillation
- Anaemia
- Hyperthyroidism (causing arryhtmias, weight loss, bowel change)
What are the most important initial investigations to perform to determine the cause of his symptoms? List 6
- ECG
- Chest Xray
- Blood pressure 24 hour monitor
- FOBT
- Full Blood Count
- EUC (for electrolyte abnormalities)
- TFTs
Other – Holter, echo, carotid USS, CT head, colonoscopy, CT abdomen may not be “initial”. Food for thought.
RACGP Feedback – Case 24
This case featured an older male who is experiencing light-headedness, near-syncope attacks and reduced exercise tolerance. He has ‘red flag’ symptoms suggestive of a possible underlying malignancy. Candidates needed to be aware of the combination of symptoms and provide possible differential diagnoses and initial investigations that would assist in determining the most likely causes of the patient’s symptoms.
The common errors in this case centred on not identifying red flag symptoms and providing only cardiovascular causes of the patient’s presentation or, again, giving non-specific answers such as reduced fitness or weight gain, despite the scenario stating he had lost weight. The information in the scenario is both relevant and consistent with the expected answers.
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
I (think) this question is a question of a moderately differentiated presentation. Its not completely differentiated and just go for it, and its not a screen for broad thinking with an undifferentiated case, but rather two sets of answers, with the trap being that you have to go moderately broad, and not miss the cue.
Its easier said than done in some circumstances because of the possibility that “its actually well differentiated but you just don’t know the answer”.
References
Murtaghs – all of it
