2024.1 KFP – Public Report

Rheumatology

Case 4: 52-Year-Old Woman with Foot and Heel Pain

• Key Areas:
  • Diagnosing Morton’s neuroma and Achilles tendinopathy
  • Management of Morton’s neuroma
  • Non-pharmacological management of Achilles tendinopathy
• Common Errors:
  • Misdiagnosing Achilles tendinopathy as plantar fasciitis or calcaneal apophysitis
  • Providing insufficient detail about reasons for referrals
  • Duplicating answers by giving similar responses in different ways
  • Non-specific answers that do not demonstrate understanding of appropriate clinical care

Case 8: 55-Year-Old Woman with Frozen Shoulder

• Key Areas:
  • Diagnosing frozen shoulder
  • Confirmatory examination findings
  • Initial management of frozen shoulder
• Common Errors:
  • General overview statements such as ‘rest’ or ‘avoid lifting’ instead of specific patient education
  • Lack of specific physiotherapy referrals or procedural interventions

Case 11: 53-Year-Old Man with Gout

• Key Areas:
  • Factors contributing to gout development
  • Appropriate diagnostic investigation
  • Long-term pharmacological management
• Common Errors:
  • Overcoding by providing more responses than requested
  • Use of words or symbols that led to extra responses

Gynecology and Endocrinology

Case 12: 21-Year-Old Female Elite Athlete with Menstrual Issues

• Key Areas:
  • Pharmacological management of menstrual difficulties
  • Identifying adverse effects of anabolic steroid use
  • Immediate investigation for significant family cardiac history (electrocardiogram)
• Common Errors:
  • Inappropriate treatments such as ‘Implanon’ or ‘Kyleena intrauterine device’
  • Listing adverse effects of corticosteroids instead of anabolic steroids
  • Prioritizing irrelevant screenings over necessary cardiac investigation

Pediatrics

Case 1: 2½-Month-Old Aboriginal Infant with Non-Specific Febrile Illness

• Key Areas:
  • Differential diagnoses for febrile illness in infants
  • Appropriate initial investigations
  • Preventative health assessment for Aboriginal and Torres Strait Islander children
  • Addressing greater health disadvantages and common adolescent health issues
• Common Errors:
  • Incorrect diagnoses such as bronchiolitis, otitis media, or acute rheumatic fever
  • Extensive irrelevant family history or unrelated symptom questions for the adolescent sister

Case 13: 7-Year-Old Boy with Abdominal Pain and Constipation

• Key Areas:
  • Additional history to indicate a serious underlying cause of symptoms
  • Non-pharmacological management of constipation
• Common Errors:
  • Providing history features already given in the clinical stem
  • Vague management answers such as ‘educate’ or ‘reassure’
  • Failure to provide specific non-pharmacological strategies for managing constipation

Case 6: 5-Year-Old Girl with Respiratory Symptoms in a Rural Setting

• Key Areas:
  • Identifying history features necessitating face-to-face review
  • Examination findings necessitating transfer to hospital
  • Medico-legal and ethical issues related to providing medical records
• Common Errors:
  • Not taking the patient’s age into account
  • Providing answers appropriate for infants rather than a 5-year-old child
  • Providing similar answers on different lines, missing the opportunity to demonstrate breadth of knowledge
  • Incorrectly refusing to provide medical records to the child’s father

Gynecology and Immunology

Case 16: 22-Year-Old Woman with Solid Organ Transplantation Requesting Cervical Cancer Screening

• Key Areas:
  • Explanation of rationale behind the changes to the cervical screening program in 2017
  • Identifying factors in the patient’s history supporting cervical screening and self-collected samples
  • Understanding the importance of immunosuppression, early sexual debut, and patient preferences
• Common Errors:
  • Describing the current screening program instead of the rationale for changes
  • Incorrectly stating that cervical screening is not required post-HPV vaccination
  • Misidentifying factors in history relevant for self-collected samples (e.g., personal history of STIs, family history of cervical cancer)

Case Evolution:

• Partner’s Scenario:
  • A transgender man aged 31 years requiring an internal vaginal examination
  • Identifying specific approaches to reduce discomfort during the examination
• Common Errors:
  • Failing to consider the unique aspects of genital examinations for transgender male patients, providing generic advice instead.

Hepatology

Case 3: 60-Year-Old Woman with Metabolic-Associated Fatty Liver Disease

• Key Areas:
  • Identifying metabolic-associated fatty liver disease (MAFLD)
  • Appropriate subsequent investigations for MAFLD
  • Non-pharmacological management advice for MAFLD
• Common Errors:
  • Providing non-specific management advice like ‘healthy diet’ instead of specific dietary or activity recommendations for weight loss

Nephrology

Case 17: 58-Year-Old Man with Impaired Renal Function

• Key Areas:
  • Identifying causative factors contributing to impaired renal function (type 2 diabetes, NSAIDs, comorbidities, medications)
  • Arranging appropriate investigations to confirm renal impairment and microalbuminuria
  • Adjusting medications based on renal function findings
• Common Errors:
  • Selecting unnecessary repeat tests instead of prioritising relevant investigations
  • Misinterpreting investigation questions, not distinguishing between initial, additional, or diagnostic tests

ENT and Respiratory Medicine

Case 18: 47-Year-Old Man with Chronic Rhinosinusitis

• Key Areas:
  • Initial pharmacological management, including cessation of nasal decongestants
  • Selecting appropriate investigations if symptoms persist
  • Considering smoking cessation management, factoring in monoamine oxidase inhibitor use
• Common Errors:
  • Prescribing bupropion for smoking cessation despite contraindications with monoamine oxidase inhibitors
  • Failing to consider medication interactions and contraindications

Endocrinology

Case 19: 16-Year-Old Girl with Symptoms of Turner Syndrome

• Key Areas:
  • Interpreting clinical information (parental height, growth chart) to make a diagnosis of Turner syndrome
  • Arranging appropriate initial investigations, particularly the karyotype
  • Providing advice on confidentiality in adolescent consultations, considering Gillick competence
• Common Errors:
  • Describing the condition without a specific diagnosis (e.g., ‘delayed puberty’, ‘primary amenorrhoea’)
  • Overlooking the importance of a karyotype in initial investigations
  • Providing answers unrelated to confidentiality or incorrectly assessing Gillick competence

Cardiology

Case 10: 69-Year-Old Aboriginal Woman Post-Myocardial Infarction

• Key Areas:
  • Identifying barriers to medication compliance
  • Strategies to assist medication adherence
• Common Errors:
  • Making assumptions about the patient based on ethnicity (socioeconomic status, education level, substance use)
  • Failing to demonstrate cultural safety in answers

Case 15: 47-Year-Old Man Requesting General Check-Up with Cardiovascular Risks

• Key Areas:
  • Identifying additional factors increasing cardiovascular disease risk
  • Providing specific lifestyle advice to reduce cardiovascular risk
  • Commencing pharmacological management for cardiovascular risk reduction
• Common Errors:
  • Providing physical symptoms instead of risk factors (e.g., ‘palpitations’, ‘chest pain’)
  • Repeating information already given in the patient history
  • Non-specific lifestyle advice (e.g., ‘lose weight’ instead of specific targets)
  • Incorrect examples of medications (e.g., ‘ACE-inhibitor, for example candesartan’)

Case 20: 69-Year-Old Man with Poorly Controlled Hypertension

• Key Areas:
  • Initial investigations and pharmacological management for poorly controlled hypertension
  • Immediate management of hypertensive urgency, including appropriate medication and patient monitoring
• Common Errors:
  • Not reading the patient’s medication history correctly
  • Providing non-pharmacological answers that did not address the question
  • Diagnostic errors, giving non-specific advice, and not following current clinical guidelines

Geriatrics

Case 14: 84-Year-Old Man in Aged Care with Asymptomatic Bacteriuria and Subsequent UTI

• Key Areas:
  • Identifying asymptomatic bacteriuria and appropriate management in aged care
  • Educating nursing staff on management of non-specific urinary symptoms
  • Pharmacological management of a urinary tract infection (UTI)
  • Management of a subconjunctival haemorrhage
• Common Errors:
  • Advising regular urine testing, which is inappropriate in aged care
  • Not administering simple analgesia or prematurely ceasing sodium–glucose cotransporter 2 inhibitors for UTI
  • Incorrect management of subconjunctival haemorrhage

Case 21: 86-Year-Old Woman in Aged Care with Hypoglycaemia and Long-Term Cognitive Impairment

• Key Areas:
  • Identifying hypoglycaemia secondary to sulfonylurea use and urgent management
  • Appropriate initial investigation of long-term cognitive impairment
• Common Errors:
  • Not recognizing hypoglycaemia as the most likely diagnosis
  • Providing vague answers without effective medical management
  • Recommending investigations that had already been performed or were not indicated by current guidelines

Gastroenterology

Case 22: 36-Year-Old Woman with Symptoms Suggestive of Irritable Bowel Syndrome (IBS)

• Key Areas:
  • Diagnosing irritable bowel syndrome
  • Initial investigations for IBS
  • Pharmacological management when conservative measures fail
• Common Errors:
  • Selecting less relevant investigations for a patient with several years of symptoms
  • Providing answers that did not address the specific patient scenario

Gynecology

Case 2: 31-Year-Old Woman with Symptoms Indicative of Endometriosis

• Key Areas:
  • Relevant history for diagnosing endometriosis
  • Appropriate initial investigations for endometriosis
  • Non-pharmacological actions for opioid therapy management
• Common Errors:
  • Misinterpreting clinical information, focusing on other diagnoses like STIs
  • Asking history already provided or irrelevant questions
  • Listing lifestyle changes instead of non-pharmacological decision-making processes for opioid prescribing

Urology and Ophthalmology

Case 23: 70-Year-Old Woman with Painless Macroscopic Haematuria

• Key Areas:
  • Differential diagnoses based on smoking history, occupational chemical exposure, and urine microscopy/culture results
  • Appropriate investigations for haematuria
  • Management of chalazion
• Common Errors:
  • Providing unrelated diagnoses (e.g., ‘renal abscess’, ‘ovarian cancer’) or non-specific answers
  • Misinterpreting the question by giving the diagnosis of chalazion rather than management strategies

Dermatology

Case 7: 41-Year-Old Man with Melanoma

• Key Areas:
  • Surgical management of melanoma, specifying appropriate margin width
  • Patient education about ongoing care and skin cancer prevention
  • End-of-life care for metastatic disease
• Common Errors:
  • Non-specific description of local excision without specifying margin width
  • Inappropriate intervals for skin examination checks
  • Overemphasis on sun protection at the expense of other skin cancer education
  • Overcoding by providing more answers than requested in end-of-life care

Case 9: 48-Year-Old Man with Scalp Itch and Hair Loss

• Key Areas:
  • Differential diagnoses for scalp itch and hair loss
  • Initial pharmacological management of scalp psoriasis
  • Non-pharmacological management advice
• Common Errors:
  • Not recognizing appropriate formulation of topical therapy for the scalp (lotion or shampoo instead of cream)
  • Lack of awareness of best practice guidelines

Pulmonology

Case 24: 65-Year-Old Man with Symptoms of Chronic Obstructive Pulmonary Disease (COPD)

• Key Areas:
  • Non-pharmacological management advice for COPD
  • Identifying additional conditions the patient is at increased risk of
  • Specific immunisations appropriate for age and medical condition
• Common Errors:
  • Giving generic lifestyle advice irrelevant to the scenario (e.g., alcohol intake, weight management)
  • Less-specific answers for immunisations (e.g., ‘influenza immunisation’ rather than age-appropriate immunisation)

Neurology

Case 25: 23-Year-Old Woman with Migraine with Aura Considering Pregnancy

• Key Areas:
  • Additional symptoms indicating a serious underlying cause of headache
  • Prophylactic medication for migraine suitable for pregnancy
  • Long-term effective contraception considering migraine with aura
• Common Errors:
  • Asking for symptoms already provided, examination findings, or irrelevant history
  • Giving acute migraine treatment rather than prophylaxis or unsuitable medications for pregnancy
  • Not recognizing that migraine with aura contraindicates combined hormonal contraception

Psychiatry and Dermatology

Case 26: 19-Year-Old Man with Social Anxiety Disorder

• Key Areas:
  • Psychological management strategies specific to social anxiety disorder
  • Understanding NDIS eligibility requirements
  • Medication for performance anxiety (e.g., propranolol)
  • Pharmacological treatment of plantar wart
• Common Errors:
  • Providing therapies not indicated for social anxiety or non-specific answers (e.g., ‘refer to psychologist’)
  • Confusing NDIS with Centrelink disability support eligibility
  • Choosing non-pharmacological treatments for plantar wart

Case 5: 48-Year-Old Man with Depression

• Key Areas:
  • Additional history to clarify depression diagnosis
  • Identifying first-line medication for depression
  • Managing acute suicidal ideation in an emergency services worker
• Common Errors:
  • Not including anhedonia and suicidal ideation in the history
  • Providing similar variations on answers rather than a broad range
  • Recommending involuntary treatment when the patient was willing to receive treatment voluntarily
  • Referring for outpatient treatment rather than urgent psychiatric review