You can find all the RACGP public exam reports here: https://www.racgp.org.au/education/registrars/fracgp-exams/exam-results
You can find a summary of what is said in these reports below.
All of the questions in the AKT are written by experienced general practitioners (GPs) who currently work in clinical practice, and are based on clinical presentations typically seen in an Australian general practice setting. The questions should be answered based on the context of Australian general practice.
It is important to carefully read the clinical scenario and question. Although more than one option may be plausible, only the most appropriate option for the clinical scenario provided should be selected.
Practice Exams
The pass rate for candidates who do the RACGP practice exam are 20-35% higher.
| Exam Cycle | Pass Rate – Did Practice Exam | Pass- Rate – No Practice Exam | Percentage Gain |
| 2020.1 | 81% | 61% | +20% |
| 2019.2 | 83% | 56% | +27% |
| 2019.1 | 70% | 36% | +34% |
| 2018.2 | 70% | 40% | +30% |
| 2018.1 | 80% | 50% | +30% |
| 2017.2 | 73% | 36% | +37% |
| 2017.1 | 71% | 39% | +32% |
| 2016.2 | 71% | 42% | +29% |
| 2016.1 | 67% | 33% | +34% |
Do the practice exams!
Success rates for candidates who do this are 20-37% higher.
RACGP Public Exam Reports
2023.2 AKT
Example 1
The clinical scenario described a male, aged 18 months, with a perianal rash and pain on defecation. His symptoms were worsening despite use of a topical barrier cream. Physical examination findings included a normal temperature. An image consistent with perianal streptococcal dermatitis was provided.
The question asked, ‘What is the MOST appropriate management?’. Of the options provided, the most appropriate response was prescription of oral cefalexin. Alternative options included topical hydrocortisone cream and topical terbinafine cream.
This is an example of a two-step question. It required candidates to diagnose perianal streptococcal dermatitis and prescribe appropriate antibiotic treatment. Perianal streptococcal dermatitis is commonly misdiagnosed and treated with topical corticosteroid or antifungal creams. This results in a delay in appropriate treatment, causing unnecessary patient distress and increasing the risk of complications.
Example 2
The clinical scenario described an Aboriginal male, aged 3 years, presenting with a discharging ear. He and his grandmother would be travelling by car for the next seven days to a remote area. Physical examination findings included pus in the ear canal and a congested tympanic membrane. The initial step of prescribing topical ciprofloxacin ear drops was given in the stem.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was prescription of oral azithromycin. Alternative options included administration of intramuscular benzathine benzylpenicillin and arranging audiometry.
This question required candidates to know the current guidelines for managing acute otitis media with perforation in Indigenous Australian patients. Aboriginal and Torres Strait Islander people have very high rates of severe and persistent otitis media. Typically, Aboriginal and Torres Strait islander populations in rural and remote communities experience otitis media of longer duration and more severe disease than that experienced by non-indigenous children. For this reason, the guidelines are clear that for high-risk patients, early intervention with antibiotic treatment is indicated. Oral amoxicillin is usually the first line treatment for acute otitis media. However, as in this case, when there is no access to refrigeration, azithromycin may be used. Acute otitis media is a common presentation to Australian general practice. It is important that GPs are able to assess patients as low or high risk and manage accordingly.
Example 3
The clinical scenario described a female, aged 55 years, presenting to a remote clinic with fatigue, nausea, abdominal pain and cough that had been ongoing for two weeks. In the past two days she had developed a fever. She had a history of type 2 diabetes and was prescribed metformin and dapagliflozin. Physical examination findings including fever, tachycardia, hypotension and focal crepitations on chest auscultation were given. Her capillary blood glucose level was normal.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was to check blood capillary ketones. Alternative options included prescription of oral amoxicillin or oral oseltamivir.
The patient in this case is presenting with pneumonia. However, her infection is insufficient to explain all of the information given in the stem. This question required candidates to recognise that this patient is prescribed a sodium-glucose co-transporter 2 (SGLT2) inhibitor and is therefore at risk of euglycaemic diabetic ketoacidosis that has been triggered by her underlying infection. Although rare, euglycaemic diabetic ketoacidosis is an important condition not to be missed as it is potentially life-threatening. Due to the normal blood sugar levels seen in this condition, it is a diagnostic challenge. It is important that GPs are aware of potentially serious complications associated with the use of SGLT2 inhibitors.
Example 4
The clinical scenario described a female, aged 35 years, presenting to a rural hospital with an itchy rash, vomiting and severe cramping abdominal pain. Her symptoms had begun 30 minutes prior when she was walking in a nature reserve. Examination findings and an image of an urticarial rash were provided.
The question asked, ‘What is the MOST appropriate initial pharmacological management?’. Of the options provided, the most appropriate response was administration of intramuscular adrenaline. Alternative options included oral cetirizine or intramuscular promethazine.
This question required candidates to recognise a case of anaphylaxis likely secondary to an insect bite. This patient’s anaphylaxis presented as the acute onset of an illness involving the skin with persistent gastrointestinal symptoms. Adrenaline is the only appropriate first line treatment for anaphylaxis. Antihistamines do not stop the progression of anaphylaxis and are not a substitute for adrenaline. There is a high risk of disability or death if anaphylaxis is not promptly and appropriately treated.
Example 5
The clinical scenario described a female, aged 33 years, presenting at 26 weeks of pregnancy with three months of a red, burning rash around her mouth. She had been using a topical emollient and metronidazole gel without significant improvement. An image consistent with periorificial dermatitis was provided.
The question asked, ‘What is the MOST appropriate management?’. Of the options provided, the most appropriate response was prescription of oral erythromycin. Alternative options included prescription of oral doxycycline or topical hydrocortisone cream.
This is an example of a two-step question. It required candidates to diagnose periorificial dermatitis and prescribe appropriate treatment in the context of the patient’s pregnancy. While doxycycline is usually a first line treatment for this condition, it is Therapeutic Goods Administration (TGA) pregnancy category D and should be avoided after 18 weeks gestation as it may cause discolouration and malformation of the teeth of the developing fetus. Treatment with a topical steroid cream is likely to result in exacerbation. As periorificial dermatitis is a very common condition seen in Australian general practice, it is important for GPs to be aware not only of first line treatments, but also of alternative treatments recommended in different situations such
as pregnancy.
2023.1 AKT
Example 1
The clinical scenario described a woman, aged 59 years, with a history of insulin-dependent type 2 diabetes, presenting for her private driver’s licence medical examination. She had recently experienced an episode of severe hypoglycaemia, requiring a bystander to administer glucagon.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was to advise a non-driving period of at least six weeks. Alternative options included providing a conditional driver’s licence, allowing her to drive with blood sugar levels >5.0 mmol/L and referring her to an endocrinologist for review.
This question required candidates to safely prioritise the next steps in managing an episode of severe hypoglycaemia. The Australian Fitness to Drive guidelines advise a non-driving period of at least six weeks following an episode of severe hypoglycaemia. The guidelines take into consideration the safety of the patient and the community as it can take several weeks for impaired hypoglycaemic awareness to resolve. While referring to an endocrinologist might be appropriate, it is likely that the patient will not be seen immediately. Therefore, in this situation, it is the responsibility of the GP to advise the patient not to drive.
Example 2
The clinical scenario described a man, aged 44 years, presenting with a cough and shortness of breath on exertion for several months. A significant smoking history was provided. He had been using over-the-counter salbutamol with some benefit. Spirometry results consistent with an obstructive pattern with minimal change post-bronchodilator were provided.
The question asked, ‘What is the MOST appropriate management?’. Of the options provided, the most appropriate response was prescription of aclidinium via inhalation twice daily. Alternative options included prescription of fluticasone via inhalation twice daily and tiotropium–olodaterol via inhalation daily.
This is an example of a two-step question. It required candidates to make a diagnosis of moderate chronic obstructive pulmonary disease (COPD) and then to select the most appropriate management. Candidates needed to apply their knowledge of the COPD guidelines to the clinical scenario. As this patient was already using a short-acting beta-agonist, the guidelines recommend a ‘step-up’ with the addition of a long-acting muscarinic antagonist. COPD is a common presentation in Australian general practice, and it is important for GPs to be able to prescribe appropriately based on symptom frequency and severity.
Example 3
The clinical scenario described a man, aged 55 years, presenting with urinary frequency, hesitancy and nocturia for four months. His urine microscopy, culture and sensitivity and prostate ultrasound were normal. Results from two recent prostate-specific antigen (PSA) tests performed one month apart were also provided. These were 4.3 μg/L and 4.4 μg/L, with a free-to-total PSA of 10% on both occasions.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was to refer to a urologist for MRI of the prostate. Alternative options included prescribing dutasteride and calculating the PSA velocity in six months.
This question required candidates to correctly interpret the PSA test result in the context of the patient’s age and symptomatology. The Australian PSA testing guidelines recommend that, for men aged 50–69 years with an initial PSA of >3.0 μg/L, a repeat PSA test should be done in 1–3 months. If the repeat PSA testing level is also >3.0 μg/L, further investigation is indicated. Patients with lower urinary tract symptoms commonly present in Australian general practice. It is important that GPs can investigate appropriately and
interpret the results of these investigations in order to exclude prostate cancer.
Example 4
The clinical scenario described a woman, aged 28 years, who was 38 weeks pregnant, presenting due to concerns about a change in fetal movements for four hours. She noted that movements varied between fast movements and no movement. A normal physical examination was provided, including a normal fetal heart rate.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was urgent referral to the obstetric unit for cardiotocography. Alternative options
included recommending the use of a kick chart and reassuring the patient.
This question required candidates to have a knowledge of the current guidelines for managing reduced fetal movements and to apply this knowledge to the clinical scenario given. It is important that GPs are aware that sustained maternal perception of a change in fetal movements requires investigation with cardiotocography to reduce the risk of stillbirth. Changed or reduced fetal movements are a sensitive indicator of fetal compromise and are associated with impaired placental function. The use of kick charts is no longer recommended, and falsely reassuring the patient could result in fetal death.
Example 5
The clinical scenario described an infant, aged 6 months, who was brought in by his mother for routine immunisations. A physical examination identified a unilateral undescended testicle located in the inguinal canal.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was immediate referral to a surgeon for orchidopexy. Alternative options included reassurance that most testes would descend by 12 months and referral to a surgeon if still not descended by 18 months.
This question required candidates to correctly make the diagnosis of an undescended testicle and then to select the correct management. Current guidelines recommend referral to a surgeon by 3–6 months of age and orchidopexy between six and 12 months of age. Undescended testis is one of the most common paediatric surgical presentations in general practice. It is important that GPs are able to refer for timely surgical correction in order to reduce the risk of malignancy and infertility.
2022.2 AKT
Example 1
The clinical scenario described a man, aged 67 years, requesting prostate cancer screening. He was asymptomatic. His prostate-specific antigen (PSA) test result of 4.1 μg/L was also provided.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was to arrange repeat PSA testing in six weeks. Alternative options included reassuring him that no further investigation is required and ultrasound of the prostate.
This question required candidates to correctly interpret the PSA test result in the context of the patient’s age. The Australian PSA testing guidelines recommend that, for men aged 50–69 years with an initial PSA of >3 μg/L, a repeat PSA test should be done in 1–3 months. If the repeat PSA testing level is also >3 μg/L, further investigation is indicated. Requests for prostate cancer screening are common in Australian general practice. It is important that GPs can counsel patients regarding the benefits and harms of screening to enable informed decision-making. GPs must then be able to appropriately interpret and manage the PSA test result.
Example 2
The clinical scenario described a woman, aged 39 years, with a history of asthma presenting for influenza immunisation. She had previously used fluticasone propionate daily for asthma prevention, but ran out six months prior and had not been using a preventer medication recently. She had been using her salbutamol inhaler once per week during the day for several months. A normal physical examination was provided.
The question asked, ‘What is the MOST appropriate pharmacological management of her asthma?’. Of the options provided, the most appropriate response was budesonide–formoterol
100 mcg/3 mcg two inhalations as required. Alternative options included continuing salbutamol as required and budesonide–formoterol 200 mcg/6 mcg inhaled twice daily.
This question required candidates to apply their knowledge of the Australian asthma management guidelines (Australian asthma handbook) to the clinical scenario. Candidates first needed to assess this patient’s asthma control as poor, given her weekly use of salbutamol. They then needed to demonstrate an understanding of appropriate ‘step-up’ regimes for poorly controlled asthma. Asthma is a common presentation to Australian general practice, and it is important for GPs to be able to prescribe appropriately, based on symptom frequency and severity.
Example 3
The clinical scenario described a man, aged 39 years, presenting with an irritated eye. He had experienced eye pain and ‘spots’ in his vision the night before while grinding metal. Physical examination findings, including a subconjunctival haemorrhage and normal, symmetrical visual acuity, were provided.
The question asked, ‘What is the MOST appropriate management?’. Of the options provided, the
most appropriate response was urgent review by ophthalmologist. Alternative options included reassurance that symptoms would settle spontaneously and prescription of chloramphenicol eye drops.
This is an example of a two-step question. It required candidates to recognise symptoms and signs consistent with an intraocular metallic foreign body and to select the correct management. While this is a rare presentation, it is a diagnosis not to be missed, as it can lead to permanent visual impairment. Therefore, urgent review by an ophthalmologist is indicated.
Example 4
The clinical scenario described a woman, aged 28 years, presenting with a severe facial rash that began after using a new cosmetic cream. The patient was 24 weeks pregnant. An image supporting the likely diagnosis of perioral dermatitis was provided.
The question asked, ‘What is the MOST appropriate pharmacological management?’. Of the options provided, the most appropriate response was prescription of oral erythromycin. Alternative options included prescription of oral doxycycline and prescription of topical methylprednisolone aceponate ointment.
This question required candidates to consolidate several pieces of knowledge and apply them to the given scenario. First, candidates needed to make the appropriate diagnosis of perioral dermatitis. The next step was for candidates to consider appropriate treatment options, while also considering contraindications. First-line treatment for severe perioral dermatitis is oral doxycycline. However, as doxycycline is not recommended after 18 weeks of pregnancy, candidates needed to select erythromycin as the preferred antibiotic in this case. As perioral dermatitis is a common presentation to Australian general practice, GPs should be aware of both first- and second-line treatment options.
Example 5
The clinical scenario described a woman, aged 22 years, presenting with a dry cough and pleuritic chest pain. Physical examination demonstrated tachycardia. Her chest X-ray was reported as normal.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was D-dimer. Alternative options included prescription of oral amoxicillin or oral diclofenac.
This question required candidates to consider the symptoms and signs of a pulmonary embolism (PE), which is a diagnosis not to be missed. Although this patient did not have specific risk factors for a PE, her symptoms and physical examination findings indicated that PE is a differential diagnosis for this case, and therefore, required PE to be excluded. Her low-risk Wells score meant that a D-dimer was the most appropriate investigation to exclude PE.
2022.1 AKT
Example 1
The clinical scenario described a woman, aged 32 years, presenting with neck pain, which radiated to her left jaw and ear. Physical examination findings including a low-
grade fever and thyroid tenderness were provided. Test results showed hyperthyroidism, elevated erythrocyte sedimentation rate and negative thyroid antibodies. Her nuclear thyroid scan showed generalised low radioiodine uptake.
The question asked, ‘What is the MOST appropriate provisional diagnosis?’ Of the options provided, the most appropriate response was subacute thyroiditis. Alternative options included acute infectious thyroiditis and Graves’ disease.
This question required candidates to correctly interpret thyroid function tests, know the causes of hyperthyroidism, apply this knowledge to the clinical scenario and arrive at the correct diagnosis for this patient. In the next most likely diagnosis, acute infectious thyroiditis, thyroid function tests are usually normal. Lastly, patients with Graves’ disease may experience neck pain; however, thyroid antibodies and radioiodine uptake on nuclear thyroid scan are usually elevated.
Example 2
The clinical scenario described a woman, aged 39 years, presenting with a hoarse voice after commencing a fluticasone–salmeterol dry-powder inhaler for asthma four months earlier. She described excellent asthma control with no use of salbutamol in three months. A normal physical examination was also provided.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to change her preventer medication to a fluticasone metered-dose inhaler via spacer. Alternative options included prescription of amphotericin lozenges and changing to montelukast.
This question required candidates to consolidate several pieces of knowledge. It required candidates to demonstrate the appropriate management of a common medication side effect and be aware of ‘step-down’ regimes when asthma is well controlled. This patient required her preventer medication to be delivered via spacer to relieve her hoarse voice. As her asthma was well controlled, it was also possible to cease her salmeterol. Asthma is a common presentation to Australian general practice, and it is important for GPs to be able to prescribe appropriately based on symptom frequency and severity while also managing medication side effects.
Example 3
The clinical scenario described a child, aged 5 years, presenting with a rash around her anus and pain on defecation. An image supporting the likely diagnosis of perianal streptococcal cellulitis was provided.
The question asked, ‘What is the MOST appropriate management?’ Of the options provided, the most appropriate response was to prescribe oral cefalexin for 10 days. Alternative options included prescription of clotrimazole cream or hydrocortisone cream.
This is an example of a two-step question. It required candidates to recognise symptoms and signs consistent with perianal streptococcal cellulitis and prescribe the appropriate treatment. A common error is to treat perianal streptococcal cellulitis as if it were a fungal or irritant dermatitis, which leads to a delay in diagnosis and appropriate treatment.
Example 4
The clinical scenario described a woman, aged 56 years, requesting repeat prescriptions. She had a coronary artery stent inserted three months earlier after a myocardial infarction. A list of medications was provided, including aspirin, clopidogrel, atorvastatin, metoprolol and low-dose ramipril. Physical examination was normal and included blood pressure at the upper limit of normal. Her fasting lipids were to target.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to increase her ramipril dose, thereby maximising the cardio-protective effect of angiotensin-converting enzyme inhibitors. Alternative options included prescription of amlodipine or hydrochlorothiazide.
This question required candidates to be familiar with the current guidelines for drug therapy after stent insertion for acute coronary syndrome. Secondary prevention by optimising drug doses reduces mortality, prevents readmissions and improves symptom control. Candidates needed to appreciate that this patient’s blood pressure was to target, and so aiming to lower blood pressure further was not required. Uptitration of post-discharge medications is often the responsibility of GPs, and it is important for candidates to demonstrate the knowledge and skills to perform this task.
Example 5
The clinical scenario described an infant, aged 10 days, presenting for review of jaundice. The pregnancy and delivery were uncomplicated. He was breastfeeding well and had normal output. Physical examination was normal apart from mild jaundice. The result of serum bilirubin demonstrating unconjugated hyperbilirubinaemia was provided.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to offer regular follow up with early review if worsening. Alternative options included gentle sun exposure and recommending formula top-ups.
This is an example of a two-step question. It required candidates to understand the differential diagnosis causing neonatal jaundice and to arrive at the correct diagnosis. Candidates then needed to demonstrate the appropriate management. Placing an infant in direct or indirect sunlight to manage jaundice is no longer recommended. There is no need for formula top-ups in an otherwise well child who is breastfeeding without difficulty and has no features of dehydration. Although candidates may be tempted to ‘do more’, in this case, observation and regular follow up was the most appropriate approach.
2021.2 AKT
Example 1
The clinical scenario described a 30-year-old woman who was 34 weeks pregnant presenting due to concerns about reduced fetal movements for six hours. A normal physical examination was provided, including a normal fetal heart rate.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was urgent referral to obstetric unit for cardiotocography. Alternative options included recommending the use of a ‘kick-chart’
and reassuring the patient.
This question required candidates to have a knowledge of the current guidelines for managing reduced fetal movements and to apply this knowledge to the clinical scenario given. It is important that GPs are aware that sustained maternal perception of a change in fetal movements requires investigation with cardiotocography to reduce risk of stillbirth. Changed or reduced fetal movements are a sensitive indicator of fetal compromise and are associated with impaired placental function. The use of kick-charts is no longer recommended, and falsely reassuring the patient could result in fetal death.
Example 2
The clinical scenario described a 4-year-old girl presenting with a fever and cough. Physical examination findings consistent with mild community-acquired pneumonia were given. Apart from a fever, her vital signs were normal.
The question asked, ‘What is the MOST appropriate initial management?’. Of the options provided, the most appropriate response was prescription of oral amoxicillin. Alternative options included reassurance that this is a viral infection and only simple analgesia is required, and transfer to the emergency department.
This was a two-step question requiring candidates to make a diagnosis and then initiate the correct management. This question required candidates to consolidate several pieces of knowledge, including recognising symptoms and signs of pneumonia, appropriately assessing the severity of the illness and knowledge of the current antibiotic guidelines for paediatric community-acquired pneumonia. Identification of a sick child and appropriate prescription of antibiotics is an important skill for GPs. Transferring this child to the emergency department would place strain on the hospital system and is unnecessary, as this child could safely be managed in the community initially.
Example 3
The clinical scenario described a 73-year-old woman presenting for advice regarding cervical screening. She had a normal Pap smear four years earlier and was currently asymptomatic.
The question asked, ‘What is the MOST appropriate management?’. Of the options provided, the most appropriate response was to perform a cervical screening test. Alternative options included advising that no further cervical screening is required and performing a co-test.
This question required candidates to be familiar with the current Australian cervical cancer screening guidelines and recommendations for exiting the screening program. There is a commonly held misconception that cervical screening is not recommended after the age of 70 years, as this was the case under the previous national screening program. It is important that GPs are up to date with guideline changes and can appropriately inform patients of current screening recommendations.
Example 4
The clinical scenario described an 18-year-old woman presenting with dizziness associated with activity. She described a strict diet and exercise routine aimed at losing weight. She had lost a significant proportion of her body weight over the prior two months. Vital signs, including significant postural tachycardia and a low body mass index, were provided.
The question asked, ‘What is the MOST appropriate next step in management?’. Of the options provided, the most appropriate response was inpatient admission to a specialist eating disorder clinic. Alternative options included referral to a psychologist for family therapy sessions and prescription of fluoxetine.
This was another example of a two-step question requiring a diagnosis, followed by identification of appropriate management. This question required candidates to have a knowledge of signs and symptoms consistent with anorexia nervosa, as well as an understanding of the medical admission criteria for eating disorders. Eating disorders
are associated with significant psychiatric and medical morbidity. Many patients with eating disorders are managed in a community setting by a multidisciplinary team that includes their GP. It is important for GPs to have the knowledge and skills to assess the need for inpatient treatment of an eating disorder.
Example 5
The clinical scenario described a 15-year-old girl presenting with a dry cough and associated wheeze for two months. She had been experiencing these symptoms weekly and was awoken by her cough twice per month. Spirometry results consistent with asthma were provided.
The question asked, ‘What is the MOST appropriate next step?’. Of the options provided, the most appropriate response was prescription of budesonide–formoterol to be taken as required. Alternative options included prescription of salbutamol as required and arranging a chest X-ray.
This question also required candidates to consolidate several pieces of knowledge, including recognising symptoms of asthma, assessing the clinical severity, interpreting spirometry results and a knowledge of the Australian asthma management guidelines for initiating treatment in adolescents. The current guidelines recommend as-required low-dose budesonide–formoterol or a regular daily low-dose inhaled corticosteroid for adolescents experiencing symptoms twice per month or more but without frequent or uncontrolled symptoms. Asthma is a common presentation to Australian general practice and it is important for GPs to be able to assess severity and prescribe appropriately.
Example 6
The clinical scenario described a 42-year-old woman presenting to a rural emergency department with palpitations and associated shortness of breath. Her physical examination revealed tachycardia, low–normal blood pressure and reduced oxygen saturations. An electrocardiogram consistent with supraventricular tachycardia was provided. The stem indicated that initial non-pharmacological management was ineffective.
The question asked, ‘What is the MOST appropriate pharmacological management?’. Of the options provided, the most appropriate response was intravenous adenosine. Alternative options included oral aspirin and intravenous amiodarone.
This is an example of a three-step question. It required candidates to recognise symptoms and signs of a decompensated arrhythmia and appropriately interpret the electrocardiogram as supraventricular tachycardia. Candidates then needed to use their knowledge of both the initial and subsequent treatment of supraventricular tachycardia. If initial Valsalva manoeuvres fail to correct the arrhythmia, adenosine is the appropriate next step. It is important for GPs to be able to appropriately diagnose and treat common emergency presentations, such as arrhythmias.
2021.1
Example 1
The clinical scenario described a 40-year-old man presenting for advice regarding cancer screening. His family history was provided and included one first-degree and one second degree relative, both diagnosed with colorectal cancer over the age of 55 years.
The question asked, ‘What is the MOST appropriate recommendation for cancer screening based upon this patient’s history?’ Of the options provided, the most appropriate response was to recommend a faecal occult blood test (FOBT) every two years from age 50 years. Alternative options included FOBT every two years from now, and colonoscopy every five years from age 51 years.
This question required candidates to have a knowledge of the current guideline recommendations for colorectal cancer screening, as outlined in the RACGP Red Book. This patient is Category 1, and therefore, has an average or slightly increased risk
(<1% 10-year risk of colorectal cancer). An FOBT is recommended every two years from
50–74 years of age. Cancer screening is a common presentation to Australian general practice, and it is important that GPs are able to appropriately advise patients regarding their risk and screening recommendations.
Example 2
The clinical scenario described a young carpet layer presenting with pain and swelling over his left patella. His symptoms were improving with the application of ice and a bandage. The image and physical examination findings provided were consistent with a diagnosis of pre-patellar bursitis.
The question asked, ‘What is the MOST appropriate next step in management?’ Of the options provided, the most appropriate response was to prescribe an anti-inflammatory medication orally for five days. Alternative options included diagnostic knee joint aspiration and prescription of dicloxacillin orally for five days.
This is an example of a two-step question. It required candidates to make the diagnosis of pre-patellar bursitis and know the appropriate management. One important differential diagnosis in this case was septic arthritis of the knee. This serious diagnosis could be excluded by the given history and examination findings. Aspirating this patient’s knee joint was completely inappropriate and risked introducing infection to the healthy joint, thereby causing septic arthritis.
Example 3
The clinical scenario described a middle-aged woman who had been referred by her surgeon for follow up of abnormal investigation results. After a serious illness and surgery, she was found to have an elevated thyroid stimulating hormone level with a normal serum thyroxine (T4) level.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to repeat thyroid function tests in six weeks. Alternative options included prescription of thyroxine 100 mcg orally and iodine supplementation.
This question required candidates to have a knowledge of the appropriate management of abnormal thyroid function tests occurring after a critical illness. This situation is consistent with the transient complex endocrine response which can occur when a patient is severely unwell. It usually resolves spontaneously, and treatment with oral thyroxine is not recommended based on thyroid function tests alone. It is important to assess for persistent thyroid disease by repeating thyroid function tests six weeks after recovery.
Example 4
The clinical scenario described an elderly woman who had sustained a left distal radius fracture one month earlier while travelling. Her fracture was treated with the application of a plaster back-slab. After removal of the back-slab, the patient was found to have symptoms and signs consistent with fracture malunion.
The question asked, ‘What is the MOST appropriate next investigation?’ Of the options provided, the most appropriate response was X-ray of the left wrist. Alternative options included dual-energy X-ray absorptiometry scan and magnetic resonance imaging
(MRI) of the left wrist.
This question required candidates to have a knowledge of possible complications following wrist fracture and the appropriate investigation when a complication is suspected. Fracture malunion occurs when a fracture heals in a non-anatomical position and can result in pain and functional limitation. When malunion is suspected, X-ray is recommended as the initial imaging modality. Further imaging with computed tomography or MRI may be required if operative management of malunion is required.
Example 5
The clinical scenario described an elderly woman with worsening of her usual cough for two months. She had a history of chronic obstructive pulmonary disease secondary to heavy long-term tobacco smoking. She had already taken a course of antibiotics, as well as a short course of oral prednisolone, without improvement. A recent chest X-ray was normal.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to arrange computed tomography scan of her chest. Alternative distractors included prescription of additional antibiotics and referral to a respiratory physician.
This question required candidates to have a knowledge of appropriate investigation of a new or changed chronic cough in a patient at high risk of lung cancer. It is important that GPs are aware that a normal chest X-ray does not exclude lung cancer and further investigation with computed tomography scanning of the chest should be arranged when there is a high index of suspicion. While referral to a respiratory physician would also result in the patient being appropriately diagnosed, it could significantly delay diagnosis and treatment depending on the time frame for the patient to be seen.
2020.2 AKT
Example 1
The clinical scenario described an elderly woman who had recently had a squamous cell carcinoma excised. The lesion was removed with appropriate macroscopic margins as recommended by current guidelines. The histopathology report detailing complete excision with appropriate microscopic margins was provided.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to advise that no further surgical management was required for this lesion. Alternative options included re-excision with larger margins and applying imiquimod to the scar.
This question required candidates to have a knowledge of the current guideline recommendations for the appropriate surgical margins for skin cancer excision. In this instance, candidates needed to appreciate that this patient had already undergone all necessary treatment for her squamous cell carcinoma. Further excision was unnecessary
and would put the patient at risk of complications associated with treatment.
Example 2
The clinical scenario described a young Aboriginal woman with a history of polycystic ovarian syndrome. She had previously completed an oral glucose tolerance test at the time of diagnosis but had no subsequent screening for diabetes mellitus.
The question asked, ‘What is the MOST appropriate screening for diabetes to recommend?’ Of the options provided, the most appropriate response was HbA1c every 12 months. Alternative options included fasting blood glucose every six months and oral glucose tolerance test every two years.
This question required candidates to be aware that Aboriginal patients are at higher risk of developing type 2 diabetes and that this patient had an even higher risk due to her history of polycystic ovarian syndrome. The RACGP’s National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people recommends screening such patients with HbA1c or fasting blood glucose every 12 months.
Example 3
The clinical scenario described an adolescent male presenting with a fever and sore throat for several days. An image was provided that clearly demonstrated the classical features of peritonsillar abscess.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to transfer the man to hospital urgently for surgical review. Alternative options included prescribing oral phenoxymethylpenicillin and prescribing oral prednisolone.
This question tested candidates’ knowledge of typical emergency presentations to Australian general practice. Due to the potential serious complications of peritonsillar abscess, including airway obstruction, urgent drainage was required. Attempting to treat this patient in the community with oral therapy would have put his life at risk.
Example 4
The clinical scenario described a young woman presenting with several weeks of painless vaginal spotting. She was not at risk of pregnancy and had a normal cervical screening test two years prior. Her physical examination was normal and an endocervical swab for chlamydia polymerase chain reaction was performed.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to repeat her cervical screening test with a co-test. Alternative options included cervical screening test and referral for colposcopy.
This question required candidates to have a knowledge of appropriate investigation of vaginal bleeding. The cervical screening test is a screening test and is not sufficient to investigate a symptomatic patient. In this circumstance, a co-test should also be requested. Candidates should not be falsely reassured by a negative test that was
performed years prior when the patient was asymptomatic. Although this patient may require a colposcopy at a later date, GPs can complete appropriate investigations before referral to a gynaecologist.
Example 5
The clinical scenario described a young man who requested a repeat prescription for his asthma medications. He had exercise-induced asthma that had been well controlled on an inhaled corticosteroid for the previous 12 months.
The question asked, ‘What is the MOST appropriate next step?’ Of the options provided, the most appropriate response was to reduce the dose of his inhaled corticosteroid. Alternative options included changing to another inhaled corticosteroid and continuing his current treatment regimen for a further 12 months.
Asthma is a common presentation to Australian general practice and it is important that GPs appropriately increase or decrease a patient’s medications as needed. The ultimate aim of stepped adjustment of asthma medication is to determine the lowest dose of medication to achieve symptom control, as per current guidelines.
2020.1 AKT
Example 1
The clinical scenario described a middle-aged female who presents after having a workplace medical assessment completed, where she was told she has an ‘abnormal’
electrocardiogram (ECG). An ECG and her medication list are provided.
The question asked, ‘What medication is MOST likely to cause the abnormality identified on the electrocardiogram?’
Of the options provided, the most appropriate response was amitriptyline. Alternative options included aspirin, atorvastatin and frusemide.
This question requires multiple pieces of knowledge to be applied to a clinical scenario. Candidates need to identify the appropriate ECG abnormality (QT prolongation), and then demonstrate that they know which medication is most likely to contribute to this problem.
Example 2
The clinical scenario described a young woman who is 10 weeks pregnant. She had attended the clinic for cervical screening, as she has never previously had one and is overdue.
The question asked, ‘What is the MOST appropriate next step regarding Anika’s cervical cancer screening?’
Of the options provided, the most appropriate response was to collect a sample of cells from the cervix using a broom-type brush. Alternative options included advising her that she does not require cervical screening, and postponing cervical screening until after the postnatal period.
This question requires candidates to be aware of the cervical cancer screening guidelines. This is a critical skill that Australian GPs are using regularly, and it is important to be aware of the required steps in special situations such as pregnancy.
Example 3
The clinical scenario described a middle-aged woman who presents for a dressing change for a wound on her foot. She had spilt boiling water on it five days prior and had been self-dressing in that time. Examination findings confirm this is a simple burn with no signs of infection.
The question asked, ‘What is the MOST appropriate dressing?’
Of the options provided, the most appropriate response was an absorbent foam dressing. Alternative options included iodine-based dressings and silver suphadiazine.
This question requires candidates to be aware which appropriate types of dressings are appropriate for different types of wounds. While nurses may be applying wound dressings in general practice, it is important for GPs to be guiding appropriate dressing selection and general wound management.
Example 4
The clinical scenario described a young male child brought in for a check-up at six weeks of age. Clinical details are provided, including the child’s birth weight, erratic sleeping pattern of waking 2–3 times at night, an occasional momentary squint appearance of their eye, a small umbilical hernia, and gain of 75 g of weight weekly. The question states you are concerned that one of these findings requires further investigation.
The question asked, ‘What is the MOST appropriate next step?’
Of the options provided, the most appropriate response was to recommend further investigation of breast milk volume. Alternative answers included referring him to a sleep clinic, referral to an ophthalmologist to consider eye patching, and organising urgent hernia repair.
This question helps elicit a candidates’ understanding of ‘normal’ in a young infant, and checks for ‘unconscious incompetence’; for example, candidates need to be aware that 75 g of weight gain a week is inadequate and that further investigation is required. If candidates are unaware that this weight is a concern, they may not know they need to investigate and thus might miss the red flag.
Example 5
The clinical scenario described a middle-aged man who is a new patient presenting for a prescription for his diabetes medication, metformin extended-release. Further details are given, including his latest HbA1c, 24-hour blood pressure monitoring result, body mass index and a urine dipstick. Cholesterol results are also provided. On the urine dipstick, he is noted to have proteinuria.
The question asked, ‘What is the MOST appropriate next step to reduce his risk of developing chronic kidney disease?’
Of the options provided, the most appropriate response was to lower his systolic blood pressure below 130 mmHg. Alternative answers included initiating aspirin, reducing his HbA1c, and initiating a statin.
This question assesses typical chronic disease management in general practice. It is important candidates are aware and understand appropriate chronic disease guidelines, including the management/prevention of chronic kidney disease.
2019.2 AKT
Example 1
The clinical scenario described an elderly male who has a slowly progressive unilateral hearing loss with no clear causal factor. An audiogram provided for interpretation demonstrated a unilateral sensorineural hearing loss.
The question asked, ‘What is the MOST appropriate next step?’
Of the options provided, the most appropriate response was a magnetic resonance image (MRI) of the patient’s head. Alternative options chosen included provision of a hearing aid and high-dose acute prednisone.
It is important that candidates are aware of red flag conditions and possible serious pathology. While conditions such as acoustic neuromas are rare, significant harm may be caused through delayed diagnosis and management.
Example 2
The clinical scenario described a middle-aged man with a right carotid artery stenosis found incidentally while undergoing an ultrasound of his neck for a possible enlarged lymph node. Further information was provided regarding his clinical examination findings, medications and blood test results. The patient’s lipid tests were particularly highlighted.
The question asked, ‘What is the MOST appropriate next step, given his carotid artery stenosis?’
Of the options provided, the most appropriate response was atorvastatin 10 mg orally daily. Alternative options selected included fish oil, metformin, and brain imaging. This question required candidates to be aware of current guidelines for managing vascular disease. Understanding management steps to prevent progression of disease is a critical and essential skill in Australian general practice.
Example 3
The clinical scenario described a middle-aged female who presents for a blood pressure medication prescription. She described per rectum blood loss that she occasionally saw in the toilet bowl, with the last episode occurring three months prior. It was also noted that the patient’s bowel habit has altered from normal. The stem explained that information regarding fluid intake, fibre etc has already been provided.
The question asked, ‘What is the MOST appropriate next step?’
Of the options provided, the most appropriate response was performing a colonoscopy. Alternative options included performing a faecal occult blood test, coagulation profile and advising the patient that she requires no further management.
It is critical that Australian GPs understand the differences between screening programs and the appropriate investigation of a patient with symptoms of potentially serious disease. This question demonstrated the importance of applying multiple pieces of knowledge to a patient’s individual context in order to come to an appropriate clinically reasoned conclusion.
Example 4
The clinical scenario described a young male child with symptoms of an upper respiratory tract infection. On examination, a soft murmur was identified. Its characteristics were described. The child is checked again when well, with the murmur barely audible on the second occasion.
The question asked, ‘What is the MOST appropriate step?’
The most appropriate response was to reassure the child’s mother that the murmur was innocent. Alternative answers included recommending provision of antibiotic prophylaxis for invasive procedures, refer to paediatric cardiologist and performing chest X-rays.
The question required candidates to be able to perform a difficult skill – reassure a patient that they are well and do not require further follow-up. It is important that candidates are confident to reassure patients when further investigations or referrals are not required.
Example 5
The clinical scenario described a middle-aged female who recently had a screening mammogram performed. She is concerned that her test may be incorrect, despite the mammogram being reported as normal. The question continues to explain that you identify a document regarding the evidence base for screening mammography.
The question asked, ‘What parameter within this report is the MOST appropriate to help answer her question?’
The most appropriate response was the negative predictive value of mammography. Alternative answers included the specificity of mammography, the false positive rate and the reliability of mammography.
The question requires candidates to demonstrate an understanding of the basic principles of evidence-based medicine. When Australian GPs make clinical decisions, they need to be aware of the evidence-based principles underlying those decisions. Increasingly, the AKT incorporates questions testing evidence-based medicine principles.
Example 6
The clinical scenario described a young female who suddenly begins choking while in a restaurant. She is making choking sounds and clutching at her throat after attempting to eat a piece of steak. She is able to breathe and mutters that she feels like something is stuck in her throat.
The question asked, ‘What is the MOST appropriate next step?’
The most appropriate response was to advise her to try to cough. Alternative answers included performing the Heimlich maneuver, using table implements to attempt to remove the foreign body, and to perform mouth-to-mouth in an attempt to blow the obstruction inwards.
The question requires candidates to demonstrate their knowledge of first-aid. It is important to remember that Australian GPs need to know how to manage acute emergencies, in multiple settings, as healthcare providers to their communities.
2019.1 AKT
Example 1
The clinical scenario describes a two-year-old child who is brought into your rural clinic while having a seizure. The seizure is taking place in the context of a febrile illness occurring over the last few days. Examination reveals tachycardia and a normal temperature, and the rest of the child’s examination, including blood-sugar level, reveals no obvious cause for the seizure. The history suggests this seizure has been going for a prolonged period of time, more than 15 minutes, and does not seem to be abating.
The question asked, ‘What is the MOST appropriate next step in management?’
Of the options provided, the most appropriate answer was to administer an appropriate dose of midazolam either intravenously, buccally or intranasally. Alternative options included continuing to monitor for a further 10 minutes, providing paracetamol, and incorrect alternative anti-epileptics.
It is important for candidates to be aware of when patients present with seizures that fall outside of the recognised period for safe observation. This presentation required knowledge of red flags and appropriate further management of an emergent situation.
Example 2
The clinical scenario described an elderly man concerned that he might be diagnosed with disease X. Disease X was described as a very serious illness that, if not picked up early, may lead to the man’s death. However, the treatment for disease X is benign and a false positive would not cause him harm. A range of tests is described with different evidence-based medicine terms.
The question asked, ‘What feature of the selected blood test is MOST important?’
Of the options provided, choosing a test with as high a sensitivity as possible was the most appropriate answer. Alternative options included specificity and predictive values.
It is important that candidates are aware of the increasing importance of studying evidence-based medicine principles when studying for their RACGP exams. With the ever-increasing pressures upon Australian GPs to remain up to date in their clinical knowledge, it is important to have an understanding of the key principles underpinning research literature that we interpret to provide the best care for our patients.
Example 3
The clinical scenario described a young man with intermittent chest pain occurring with exertion over a period of seven days. These pains were described as typical cardiac chest pain, including pressure, diaphoresis, and shortness of breath. His last episode of pain was four hours ago, but he is currently pain-free. He has the complicating factor of type 2 diabetes, for which he takes medication. His clinical examination is currently unremarkable and his electrocardiogram (ECG), without pain, has no ischaemic changes.
The question asked, ‘What is the MOST appropriate next step?’
Of the options provided, transferring this patient urgently to the nearest emergency department was the most appropriate. Alternative answers included getting a stress test, organising a computed tomography (CT) pulmonary angiogram, or organising a holter-monitor.
The question required candidates to have familiarity with typical cardiac chest pain symptoms, realise the increased risk of atypical presentations in a patient with diabetes, and be alerted to the urgency in this patient’s presentation possibly going on to have a more significant cardiac event. It is important for candidates to be aware that stress testing is significantly contraindicated in a patient with current possible undiagnosed cardiac chest pain.
Example 4
The clinical scenario described a young woman who has returned for her cervical screening test results. Her result was positive for an oncogenic human papillomavirus (HPV) (not 16/18), with a liquid-based cytology result of a possible low-grade squamous cell lesion (pLSIL). Clinically, her cervix appears normal and a previous Pap smear two years prior was normal. All prior Pap smears were also normal.
The question asked, ‘What is the MOST appropriate management?’
The most appropriate response was a repeat HPV test in 12 months. Alternative answers included cervical screening in five years, and referral for colposcopy.
This question required candidates to have familiarity with the recently updated cervical screening program. This question was taken directly from the current guidelines, which the majority of GPs are likely using on a regular basis. It is important for candidates to be aware of new guidelines and be preparing for their exams by understanding currently recommended screening practices.
Example 5
The clinical scenario described a man with Down syndrome brought in by his mother for a health check-up. It describes performing some routine screening tests and reinforcing preventive health and social supports. It describes the review of some basic blood tests ordered elsewhere. His mother asks whether there are any further specific tests the man may need because he has Down syndrome.
The question asked ‘What is the MOST appropriate additional blood test to order?’
The most appropriate response was a thyroid-stimulating hormone test. Alternative answers included coagulation studies and iron studies.
The question required candidates to have some familiarity with the care of Down syndrome patients. Candidates who are aware of the increased presentation of thyroid disease within this population selected the most appropriate response. Candidates should aim to be aware of the different presentations of disease and epidemiology of pathology in patients from different biopsychosocial backgrounds.
2018.2 AKT
Example 1
The clinical scenario describes a young Aboriginal child who presents to a clinic with a high fever, rhinorrhoea and cough over the last seven days. Her examination revealed an erythematous pharynx and erythematous tympanic membranes. Auscultation of her chest revealed mixed crackles and wheeze within the lung fields.
The question asked ‘What is the MOST appropriate provisional diagnosis?’
Of the options provided, the most appropriate answer was community-acquired pneumonia. Alternative answers that were selected included bronchiolitis or asthma. It is important that candidates read the question presented carefully and consider all information provided. For example, the selection of bronchiolitis was either due to a lack of demographic knowledge for this illness or candidates not reading the question carefully enough, particularly since the child’s age would make this diagnosis unlikely.
It is important for candidates to be aware that pneumonia is significantly more likely in Aboriginal and Torres Strait Islander populations than in the non-Indigenous population. Indigenous children in the Northern Territory, for example, have rates of radiologically confirmed pneumonia that are among the highest in the world.
Example 2
The clinical scenario described a young woman with a non-tender, dark discolouration beneath one of her fingernails. The colour had been present for a few weeks and she believed it may have increased slightly and moved minimally towards the distal end of her finger during that time. An image of the discolouration under the nail was provided that supported a diagnosis of subungual haematoma.
The question asked ‘What is the MOST appropriate next step in management?’
The most appropriate next step from those provided was to give reassurance that the condition will self-resolve without intervention. Alternative answers that were selected included surgical biopsy of the nail matrix and referral to a dermatologist for a second opinion.
It is important that candidates are aware of common presentations to Australian general practice. This presentation did not fit with the slow onset and typical pattern of a subungual melanoma. Also, the image provided was a classic subungual haematoma. Surgical biopsy of the nail matrix can lead to significant discomfort and is unnecessary for a subungual haematoma. Referral to a dermatologist for this benign condition is not required and would increase the overall costs of managing the condition.
Example 3
The clinical scenario described an adolescent patient with three weeks of right knee pain, causing a limping gait. The pain was worse when playing netball or climbing stairs. On clinical examination she was tender over her tibial tubercle.
The question asked ‘What is the MOST appropriate next step?’ The most appropriate answer of those provided was to perform quadriceps strengthening exercises and modify the patient’s activities. Alternative answers selected included imaging or use of regular non-steroidal anti-inflammatory drugs.
The question required candidates to make the appropriate provisional diagnosis of Osgood–Schlatter disease based upon the patient’s age, the classic presentation, and knowledge of the anatomical location of the pathology. Using an appropriate understanding of the pathophysiological mechanisms of the condition, candidates were then required to select the most appropriate answer. From alternative answers, an X-ray is only required when the clinical presentation is atypical. Regular ibuprofen is unlikely to help the symptoms and may cause harm.
Example 4
The clinical scenario described an older gentleman who had symptoms consistent with a transient ischaemic attack (TIA). He had a history of diabetes and a soft cardia murmur on clinical examination. He underwent a computed tomography (CT) of his head with no abnormalities identified, and also had an electrocardiogram and echocardiogram.
The question asked ‘What is the MOST important next investigation?’
The most important next investigation from those provided was a Doppler ultrasound of his carotid arteries. Alternative answers selected included repeating his head CT at 48 hours and application of a Holter monitor.
This question required candidates to identify the symptoms of a TIA, the patient’s risk factors for possible carotid plaque involvement and that he needs a carotid Doppler ultrasound performed. It is critically important that Australian GPs clearly recognise the importance of a complete clinical work-up after a TIA as this patient’s risk of having a further cerebrovascular event is very high. The clinical guidelines for the management of stroke and TIA are very clear on the investigations to perform after an event and should be well studied by candidates.
Example 5
The clinical scenario described a young man who had multiple small perianal lumps. An image was shown of perianal warts. He has tried several previous treatments, including podophyllotoxin and cryotherapy, with minimal improvement.
The question asked ‘What is the MOST appropriate next step in management?’
The most appropriate answer was imiquimod 5% cream three times weekly. Alternative answers selected included curette
and cryotherapy and topical salicylic acid.
This question required candidates to be familiar with the appropriate management steps of perianal warts. At the specialist level of the Fellowship examination, it is important that Australian GPs are aware of a step-wise approach to management options – particularly if previous options have failed. Thus, this question asked for further management options for this patient’s perianal warts. Cryotherapy can be used in some settings but not with curette. As this patient had a number of lesions, cryotherapy with curette may cause significant morbidity. Salicylic acid is unlikely to be sufficiently potent and is not recommended as a standard treatment option for this condition.
2018.1 AKT
Example 1
The clinical scenario described a middle-aged female who was admitted to a rural hospital with symptoms of renal colic. She was managed overnight with simple analgesia, and appropriate investigations were normal except for mild haematuria on urine dipstick. An ultrasound report was provided that described a 4 mm renal stone with no complicating features. The patient was asymptomatic in the morning with the ongoing use of non-steroidal anti-inflammatory drugs (NSAIDs).
The question asked, ‘What is the MOST appropriate next step?’
Of the options provided, the most correct option was to discharge the patient home with NSAIDs and arrange appropriate follow-up. Alternative options included immediate surgical intervention, prophylactic antibiotics, and advising reduction in calcium intake.
This question required candidates to have familiarity with the clinical course of a kidney stone, understand its initial management, and have a good understanding of safe discharge planning. They needed to also consider this within the context of a rural setting.
Example 2
The clinical scenario described a middle-aged female who presents for a repeat of her ‘rash’ cream. The rash was described as an intermittent painless rash between her fingers. She had a history of recurrent urinary tract infections requiring repeated courses of a specific antibiotic, and the rash appeared during these times. Examination details described the location of the rash, and an image of the rash was also provided.
The question asked, ‘What is the MOST likely diagnosis?’
Of the options provided, the most correct answer was a fixed drug eruption. Alternative options included eczema,
irritant dermatitis, and discoid lupus erythematosus.
The question required candidates to think about the rash in the context of the patient’s presentation. They needed to consider the possible time–course link between recurrent courses of an antibiotic and the patient’s rash. It required candidates to also be familiar with alternative listed diagnoses and identify that these are less likely within this clinical presentation.
Example 3
The clinical scenario described an elderly male who wanted to undertake an airplane flight but takes some medication for a respiratory condition and was uncertain if he could safely fly. His clinical presentation described his risk factors and an exercise tolerance consistent with a history of mild chronic obstructive pulmonary disease
(COPD). He was on appropriate medication and his symptoms were well controlled. His examination features were consistent with his diagnosis and its severity. A spirometry result was provided to allow objective grading of the severity of the patient’s COPD.
The question asked, ‘What is the MOST appropriate management?’
Of the options provided, the most correct answer was to give approval for the patient to fly without alteration to his current management. Alternative options included provision of nasal oxygen, prophylactic antibiotics, and referral to a respiratory specialist for approval.
This question required candidates to make the appropriate diagnosis of COPD, then to grade its severity. It required interpretation of the spirometry to identify that this gentleman has mild disease with minimal ongoing symptoms. The question did not require in-depth knowledge of the rules for medical clearance for airplane flight in a patient with COPD, because candidates with familiarity with COPD management would identify that this patient has only mild, stable disease.
Example 4
The clinical scenario describes a middle-aged male who presents concerned about an increase in the size of his breast tissue. The scenario explains that he has a history of benign prostatic hypertrophy (BPH) and has recently commenced new medication that has improved his symptoms. Unfortunately, he cannot remember the medication’s name. His clinical examination was consistent with his presentation.
The question asked, ‘What medication is the MOST likely cause of his presenting symptoms?’
Of the options provided, the most correct answer was dutasteride. Alternative options were other medication options used for treating BPH.
The question requires candidates be familiar with the appropriate medications for BPH. It then requires them to demonstrate their knowledge of possible side effects of the medication options.
Example 5
The clinical scenario describes a phone call from a retirement home about an elderly male with a history of Parkinson’s disease who has had a cough and increasing breathlessness over the last week. The caller explains that the patient had experienced vomiting and diarrhoea recently, as had many other residents due to an unfortunate outbreak of viral gastroenteritis. A description of the clinical examination performed by the nursing home nurse described mild tachycardia, borderline temperature, mild tachypnea, and that the patient sounded
‘wheezy’ while seated.
The question asked, ‘What is the MOST appropriate provisional diagnosis?’
Of the options provided, the most correct answer was aspiration pneumonia. Alternative options included acute heart failure,
Bordetella pertussis infection, and Salmonella septicaemia.
The question required candidates to understand the possible comorbidities associated with Parkinson’s disease, including possible swallowing limitations. Associated with the recent vomiting illness and the current presentation of respiratory difficulty, the most appropriate provisional diagnosis was aspiration pneumonia.
2017.2 AKT
Example 1
The clinical scenario described a middle-aged female executive who has had episodes of palpitations. She presents during one of these episodes feeling slightly anxious but with no chest pain and is haemodynamically stable. An electrocardiogram (ECG) is given within the question for candidates to interpret; the ECG demonstrated supraventricular tachycardia.
The question asked: ‘What is the most appropriate initial management?’
The correct response was vagal stimulation. Approximately three-quarters of the candidates answered the question correctly; the alternative responses chosen by the remaining candidates included rebreathing into a paper bag, and an adenosine IV bolus.
This question highlights the initial management of a presentation that is not infrequently encountered in Australian general practice. While adenosine may be considered, it is not the most appropriate initial management within primary care in the otherwise stable patient.
Example 2
The clinical scenario described a middle-aged male patient who presents after experiencing repeated trauma to the front of his knee while renovating his house. He has noticed increasing swelling and worsening pain over several days. He has a tender swelling localised to the anterior part of his knee, and the rest of his knee examination is normal.
The question asked: ‘What is the most likely diagnosis?’
The correct response was prepatellar bursitis. Knee pain is a common presentation to Australian general practice. This typical presentation of trauma to the front of the knee, associated with an isolated swelling within that location, led three-quarters of the candidates to select the correct response.
Alternative answers selected by the remainder of candidates included patella tendonitis (which is less likely to present with swelling and less specific to this presentation), and pes anserine bursitis (which did not fit with the clinical description of the location of the swelling, is generally smaller, and less likely to present in this way).
Example 3
The clinical scenario described an elderly woman who presents to the clinic with a two-year history of worsening cough and increasing sputum production. Over the prior few months, her sputum had become thicker and more copious. She has no history of smoking and her exercise tolerance has been appropriate for her age. A chest X-ray report is provided that is described as normal.
The question asked: ‘What is the most appropriate investigation to confirm your provisional diagnosis?’
The correct response was a high-resolution CT scan of the chest. Cough is a common presentation to Australian general practice and it is important that candidates are aware of the presentation of bronchiectasis. A high-resolution CT of the chest is the most appropriate investigation to confirm this diagnosis. Approximately two-thirds of candidates answered this correctly.
Alternative options selected by the remainder of candidates included endoscopic examination of sinuses (for presumed chronic sinusitis or nasal polyposis – neither of which have symptoms consistent with those described), and sputum microscopy and culture (which is not a good confirmatory test for the provisional diagnosis, and may only reveal colonisation of the lungs).
Example 4
The clinical scenario described a fictional new drug treatment that claims to reduce the chance of myocardial infarctions in high-risk patients. The question described, numerically, a larger reduction in cardiovascular events in the intervention group compared with the control group. The question continues with a pharmaceutical sales representative informing you that there is a reduction in the occurrence of myocardial infarction in those who use the drug by X percentage.
The question asks: ‘What type of evidence-based measure is being described by the pharmaceutical sales representative?’
The correct answer was ‘relative-risk reduction’. This question was correctly answered by half of the candidates.
Alternative answers selected by the majority of incorrect candidates included absolute-risk reduction, and incidence. It is important that Australian GPs have a strong understanding of how statistical data are presented to them and their appropriate interpretation.
Example 5
The clinical scenario described a seven-day-old neonate presenting to their GP with mild jaundice. The question describes the birth history, which includes a vacuum-assisted delivery and a subsequent cephalohaematoma. No other risk factors or concerns are in the history, the baby is formula fed, and the examination of the neonate is otherwise normal.
The question asked: ‘What is the most likely cause of her jaundice?’
The correct answer was resolution of ecchymosis.
Often candidates do not appropriately read the question. For example, the clinical scenario described that the baby was formula fed; however, some candidates still chose ‘breast milk jaundice’ as the most likely cause. While many alternative answers selected by candidates included more complex causes such as hypothyroidism, there were no other features of hypothyroidism provided. It is important that candidates use their clinical reasoning skills to consider all features of the information provided in the scenario before selecting their answer.
2017.1 AKT
Example 1
This question included a description of a middle-aged man who was at home when he felt light-headed and experienced palpitations. An electrocardiogram (ECG) was provided along with the clinical presentation scenario. The question asked candidates to determine the most likely cause of the man’s symptoms. The correct answer was complete heart block.
Alternative answers chosen by candidates included first-degree heart block and second-degree heart block. The difference in the interpretation requires understanding of the relationship between the P wave and the QRS complex.
It is important that candidates have appropriate skills in interpreting ECGs. For example, the management of a complete heart block may vary significantly from other types of blocks.
Example 2
This question included a description of a new medication designed to reduce cardiac events, with candidates given statistical information regarding a recent clinical trial.
The question asked candidates to determine what type of evidence-based measure was described. The correct answer was relative risk.
Alternative answers chosen by candidates included absolute risk and positive predictive value. It is important for candidates to be aware of the key differences between absolute risk and relative risk. Relative risk differences may be reported as very large amounts; however, the absolute difference may be very small – indicating possibly minimal clinical benefit.
Being able to identify the features of statistical information described in clinical trials is important for critical appraisal of literature and helps to guide appropriate clinical management decisions.
Example 3
This question included a description of a young woman experiencing sub-optimally controlled asthma while on her current moderate dose of inhaled corticosteroid.
The question asked candidates to determine the most appropriate next step in the woman’s management.
The correct answer was the addition of long-acting beta agonist to her inhaled corticosteroid. Alternative answers chosen by candidates included increasing her inhaled corticosteroid to the maximal dose or initiating montelukast.
The correct interpretation required knowledge of the Australian Asthma Handbook and the step-wise approach for up-titration of medication, and application of this knowledge to the epidemiology and disease pattern of the patient in the scenario
Example 4
This question included a description of a young man who fell onto his hyperextended wrist. He has pain in the anatomically described ‘snuff box’.
The question asked candidates to determine the most appropriate initial form of imaging.
The correct answer was a plain X-ray. Alternative answers chosen by candidates included a computed tomography (CT)
scan and ultrasound.
It is appropriate to initially perform a plain X-ray when assessing and investigating a possible scaphoid fracture, as this may identify the pathology in up to 70% of cases. Further imaging decisions, such as CT or magnetic resonance imaging (MRI), depend on clinical requirement or continued uncertainty of diagnosis after the initial plain X-ray. It is important for candidates to be aware of the rational and appropriate initial imaging modality for different types of suspected orthopaedic pathology.
Example 5
This question included a description of an older man with increasing lower urinary tract symptoms over six months. A normal urinalysis is provided along with a prostate-specific antigen (PSA) result, which is slightly above normal. As in all questions where a result is given, the normal range is provided.
The question asked candidates to determine the most likely cause of the man’s symptoms.
The correct answer is benign prostatic hypertrophy. Alternative answers chosen by candidates included prostate cancer and chronic prostatitis.
It is important for candidates to be aware that elevated PSA levels can be caused by many factors. In the setting of slightly worsening lower urinary tract symptoms, as described within this question, the most likely cause is the common condition of benign prostatic hypertrophy. Lower urinary tract symptoms in prostate cancer are a late sign and less likely than benign prostatic hypertrophy. Chronic prostatitis may present with some findings on urinalysis and is less likely than benign prostatic hypertrophy given its epidemiology and the patient’s slow worsening of symptoms over a prolonged period of time.
Example 6
This question included a description of an older man who recently had a transient ischaemic attack (TIA) in hospital and discharged against medical advice. Appropriate investigations and results described were all normal. His medication includes an angiotensin-converting-enzyme (ACE) and a statin. He told his GP that the doctors in the hospital suggested he take another medication, but that he could not remember what it was.
The question asked candidates to determine the most important medication to initiate.
The correct answer was aspirin. Alternative answers selected by candidates included warfarin and apixaban.
It is important for candidates to be aware of medications required for ongoing pharmacological management of their patients following an acute event. The question did not describe any symptoms or findings consistent with atrial fibrillation where warfarin or a new oral anticoagulant (NOAC) may be indicated. Aspirin, however, is recommended routinely after any TIA unless contraindicated or another medication is used in its stead.
2016.2 AKT
Example 1
The clinical scenario describes a woman aged 36 years with a persistent rash on the dorsum of her right hand that is spreading. The image shows discrete papules with a rough, irregular surface.
The question asks for the MOST likely diagnosis.
The correct response is common warts. The age of the patient and appearance and distribution of the lesions make common warts the most likely diagnosis. Some candidates selected molluscum contagiosum and psoriasis.
The appearance and distribution of the lesions is not typical of psoriasis. Psoriasis produces plaques of thickened, scaling skin and commonly affects the skin of the elbows, knees, and scalp. Molluscum contagiosum papules tend to be uniform in appearance, usually very round with an umbilicated or dimpled centre. In contrast, the lesions shown in the image have a rough irregular surface without central umbilication. Molluscum contagiosum is more common in children, but when it does occur in adults it has a predilection for the groin and genital areas. The age of the patient and the distribution of the lesions should also point to common warts as the most likely diagnosis.
Example 2
The clinical scenario describes a man aged 38 years who was diagnosed with right Achilles tendinopathy two weeks ago after running his first half-marathon. Despite following your advice to rest from running, he continues to complain of pain in his right heel. Examination findings and ultrasound have confirmed your clinical diagnosis.
The question asks for the MOST appropriate next step in management and the correct response is referral to a physiotherapist.
Most acute tendon injuries in young healthy individuals are due to overuse or malalignment and will settle with 1–2 weeks of rest. The most appropriate second line treatment when symptoms have not responded to rest is referral to a physiotherapist or exercise physiologist for stretching and strengthening exercises. Some candidates selected non-steroidal anti-inflammatory medication and cortisone injection. As there is very little inflammatory component in Achilles tendinopathy, neither non-steroidal anti-inflammatory medication or cortisone injection into the tendon is likely to be of benefit. In fact, cortisone injection has been shown to increase the likelihood of scarring and weakening of the tendon.
Example 3
This question refers to a woman aged 51 years with a two-month history of a smooth, non-tender midline swelling in the neck which moves with swallowing. She is otherwise well and a recent full blood examination and thyroidstimulating hormone (TSH) test is normal.
The question asks for the MOST appropriate next step.
The correct response is thyroid ultrasound. Some candidates selected fine needle aspiration cytology or no further investigation. The lump described in the clinical scenario is likely to be a thyroid lump as it is midline and moves with swallowing. Although the lump has benign features and TSH is normal, further evaluation with a thyroid ultrasound is required and is the most appropriate next step. Thyroid ultrasound will confirm if the lump is arising from the thyroid or an adjacent structure, will assess the size and echogenicity of the lump and identify features that may warrant a biopsy. Although fine needle aspiration cytology may be necessary if there are ultrasound features suggestive of malignancy, it is not the most appropriate next step.
Example 4
The clinical scenario describes an asymptomatic male aged 23 years seeking sexual health advice. He has been having protected casual oral and anal sex with a male partner for the past 12 months. He does not use recreational drugs during sex. HIV testing two years ago was negative.
The question asks how often he should be offered sexually transmitted infection screening and the correct response is every 12 months.
Some candidates selected every three months, every six months or opportunistically.
This question requires the candidate to recognise the increased risk of sexually transmitted disease in men who have sex with men (MSM). Opportunistic screening is not appropriate in this clinical scenario and may have significant biopsychosocial implications for both the patient and the community. Screening more often would be indicated if MSM are involved in more risky activities including the use of recreational drugs during sex or unprotected anal sex. As the clinical scenario in this question clearly states that he does not use recreational drugs during sex and that he always uses protection, a screening interval shorter than 12 months is not warranted.
Example 5
The clinical scenario describes an asymptomatic man aged 45 years who presents to your regional medical practice for a blood pressure check. He had a 25 packet year history of cigarette smoking but quit smoking last week. He is otherwise well and active, going to the gym and playing golf regularly. Spirometry result is consistent with mild COPD.
The question asks for the MOST appropriate initial management and the correct answer is no change to current management.
Candidates selected a range of options including initiation of salbutamol MDI, initiation of long-acting beta agonist/
long-acting muscarinic therapy, initiation of short-acting muscarinic therapy and pulmonary rehabilitation.
It is important to recognise that COPD severity guides both pharmacological and non-pharmacological therapy. The aim of treatment is to reduce and control symptoms, decrease exacerbations and improve exercise tolerance and patient quality of life. The patient described in the clinical scenario has mild airflow limitation but is asymptomatic with good exercise tolerance and quality of life, and has recently stopped smoking. Appropriate initial management in this patient is smoking cessation and exercise, which the patient has already undertaken.
2016.1 AKT
Example 1
The clinical scenario describes a 48-year-old man who migrated from Syria eight years ago and presents with recurrent bouts of cough with sputum over the past two years. There has been a recent exacerbation of his symptoms associated with an episode of haemoptysis. Examination shows bilateral basal crackles and digital clubbing.
The question asks for the MOST likely diagnosis.
The correct response is bronchiectasis. The recurrent nature of his symptoms and the presence of bilateral chest signs make bronchiectasis the most likely diagnosis. Some candidates selected bronchial carcinoma and tuberculosis.
The haemoptysis and clubbing may suggest lung cancer but the prolonged, recurrent and intermittent nature of his symptoms should redirect you to the other possible diagnoses. Tuberculosis is less likely as a diagnosis because he would have been screened for the disease on his arrival in Australia. The clinical scenario also mentions that he has not been overseas since migrating to Australia, which would not support the diagnosis of tuberculosis.
Example 2
This question is about the use of prophylactic oseltamivir in an aged care facility where there has been a case of influenza A.
The question asks for the most important result to review before prescribing oseltamivir.
The correct response is eGFR.
Oseltamivir carboxylate, the active agent, is eliminated by glomerular filtration and renal tubular excretion. The dosing frequency of oseltamivir needs to be adjusted in renal impairment and data is available on the appropriate dosing frequency to use, depending on the degree of renal impairment. This information confirms that eGFR is the most important result to review before prescribing oseltamivir. Some candidates selected liver function tests. Oseltamivir is converted to the active agent oseltamivir carboxylate by hepatic enterases, but as hepatic exposure is brief and hepatic metabolism is minimal, dose adjustment is not required for impaired liver function.
Example 3
This question refers to a 40-year-old man who presents with a swollen right knee. He landed heavily on his bent knee after jumping a fence. Examination shows maximal tenderness over the medial joint line, which is worse on varus stressing of the joint.
The question asks for the MOST likely diagnosis.
The correct answer is meniscal injury. The nature of the injury described in the clinical scenario is the usual type of injury that causes meniscal tears. Meniscal tears occur as a result of a twisting force on a weight loaded flexed knee. The examination findings are also consistent with a meniscal injury. Some candidates selected collateral ligament injury. The mechanism of injury and examination findings would not support the diagnosis of collateral ligament injury.
Example 4
The clinical scenario describes an 11-year-old girl with acute abdominal pain. There is no associated vomiting. She has not opened her bowels for 36 hours. Examination findings include a fever, generalised abdominal tenderness, which is worse with percussion.
The question asks for the MOST appropriate diagnosis.
The correct response is appendicitis.
Appendicitis is a common cause of abdominal pain in children and may present with atypical symptoms. Acute appendicitis in young children may not have the classical symptoms of nausea, vomiting and loss of appetite. Percussion of the abdomen elicits a form of ‘rebound tenderness’ when there is peritoneal irritation. Some candidates selected constipation and mesenteric adenitis. The presence of fever in the examination findings makes constipation an unlikely diagnosis. Mesenteric adenitis is often associated with an upper respiratory tract illness and usually presents with right lower quadrant tenderness rather than generalised tenderness.
Example 5
The clinical scenario describes a 46-year-old woman who mentions a six-year history of bilateral nipple discharge when she presents for a breast check. The discharge occurs with expression, is yellowish and comes from more than one duct. Examination is normal and a mammogram 12 months ago was also normal.
The question asks for the MOST appropriate next step.
The correct answer is to advise that no further investigation is required. The history and examination findings are consistent with a physiological discharge. Physiological discharge is usually yellow, milky, or green in appearance; does not occur spontaneously; and can be seen originating from multiple ducts. Physiological nipple discharge is no cause for concern and requires no specific investigation. Some candidates selected ‘obtain a smear of the discharge for cytology’ as the MOST appropriate next step. The six-year history, the features of the discharge, normal examination findings and normal screening mammogram 12
months ago make a malignant cause unlikely.