Be prepared for the KFP​

Bob Miller aged 53 years presents following a volunteer shift with the local country fire authority (CFA). Bob was assisting colleagues with bushfire management over the past two days. Bob states that he was wearing full protective equipment and had a well fitted mask. He has noted a night-time cough and chest tightness over the past 1 week. He has also had  2-3kg weight gain over the past 3 months. He has a past history of hypertension and anxiety.

Bob currently takes an ACE inhibitor and St John's Wort. Bob lives with his wife and two teenage sons. His sleep has been disturbed over the past week and he says he had difficulty falling asleep before his cough started. On examination he appears well, he is afebrile, BMI 26, BP 150/80, HR 68 reg, RR 12, O2 sat 98% RA.

What are the MOST likely diagnoses for Bob’s cough?
List four (4) in note form.

What are the MOST likely diagnoses for Bob's cough?
List four (4) in note form.

Marking guide:

ACE inhibitor side effect (1 point)
Asthma (1 point)
Inhalation injury (1 point)
Viral cough (1 point)
Congestive cardiac failure (1 point)
Gastroesophageal reflux disease (1 point)

What key features on examination would assist you in determining Bob’s most likely diagnoses?
List five (5) in note form.

What key features on examination would assist you in determining Bob’s most likely diagnoses?
List five (5) in note form.

Marking guide:

Stridor (2 points)
Hoarse voice (2 points)
Facial swelling (2 points)
Expiratory wheeze (2 points)
Elevated JVP (1 point)
Bilateral Ankle oedema (1 point) 
Bronchial breath sounds (1 point)  

What is your NEXT investigation for Bob?
List one (1) answer in note form.

What is your NEXT investigation for Bob?
List one (1) answer in note form.

Marking guide:

Spirometry (1 point)

What public health issues does bushfires cause in rural Australia?
List six (6).

What public health issues does bushfires cause in rural Australia?
List six (6).

Marking guide:

Sanitation issues (1 point)
Increased suicide risk (1 point)
Water safety (1 point) 
Food security (1 point) 
Infection control issues (1 point)
Loss of accommodation (1 point)
Compromised access to health care (1 point)
Loss of community health services (1 point) 

The KFP is a tough exam and therefore it is vital to read the stem accurately. This case presents a middle-aged man who has recently assisted the Country Fire Authority and developed a cough with non-specific chest symptoms over the past week.

The MOST likely  diagnoses are inhalation injury because of potential smoke exposure, ACE inhibitor side-effect as his current medications include enalapril and asthma as this is a common diagnosis for night-time cough.

Other possible diagnoses include CCF, GORD and respiratory infection.

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Examination findings will be based on determining what the MOST likely diagnosis is. Hence, the answer grid represents specific examination findings that would represent the diagnostic options considered:

asthma - expiratory wheeze

burn injury - stridor, facial swelling, hoarse voice

CCF – elevated JVP, bilateral ankle oedema, bronchial breath sounds

Note, fever is not included as a KEY examination finding as this is already provided in the stem and it is important not to repeat given information in a KFP answer.

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Domain 3 in the current RACGP curriculum looks at population health in the context of general practice. The last question in this case is mapped to this domain. Bushfires are a not uncommon public health concern in Australia. The effect of bushfires can affect infection control, access to food, water, housing, health care. As a community GP having awareness of this risk is vital.

Further reading:

Bushfires and human health in a changing environment. Dr F Johnson. Australian Family Physician Vol. 38, No. 9, September 2009