RACGP-SAPT-2024-Nov-KFP

Case 1: Giulia Tangredi

Question 1

Giulia Tangredi, aged 63 years, reports a six-month history of progressively worsening itchy vulva. She finds it embarrassing when she needs to scratch. Her vulva has sometimes bled after scratching, and she has found passing urine and opening her bowels uncomfortable.

Giulia has a past medical history of hypertension and hypercholesterolaemia, for which she takes telmisartan 40 mg orally daily and rosuvastatin 10 mg orally daily. She has no known allergies. She does not smoke and has two standard drinks of alcohol one night per week.

On examination, Giulia looks well. Her temperature is 36.9°C, blood pressure is 133/87 mmHg, heart rate is 81/min regular, respiratory rate is 14/min, oxygen saturation is 96% on room air and body mass index is 24.5 kg/m². You note the appearance of her vulva (see image). The remainder of her examination is normal.

What is the single most likely diagnosis? Write one (1) specific diagnosis.

1…..

Question 2

You arrange appropriate investigations, which confirm the single most likely diagnosis.

Apart from the use of emollients, what pharmacological management action is appropriate? Write one (1) specific pharmacological management action, including frequency. Brand names are acceptable.

1……..

Question 3

Giulia is managed appropriately.

Six months later, Giulia returns reporting a four-month history of a worsening itchy rash on her face.

On examination, Giulia looks well. Her temperature is 36.7°C, blood pressure is 141/92 mmHg, heart rate is 85/min regular, respiratory rate is 13/min, oxygen saturation is 97% on room air and body mass index is 24.7 kg/m². You note the appearance of her face (see image). The remainder of her examination is normal.

Apart from the use of emollients, what initial pharmacological management options are appropriate? Write two (2) specific pharmacological management options, including route of administration and frequency.

…..
……

Case 2: Hayley Oaks

Question 4

Hayley Oaks, aged 27 years, presents to your rural clinic for pregnancy advice. She has had two home urine pregnancy tests today that were positive. She says her last menstrual period was eight weeks ago and her usual cycle is every 29 days and regular. She says she is very surprised that she is pregnant because she has been taking the oral contraceptive pill but admits that she has ‘missed a few pills’.

Despite her surprise, she is happy to be pregnant and wants to continue her pregnancy.

Hayley does not have any significant past medical history. She takes cyproterone acetate/ethinyloestradiol 2 mg/35 mcg orally daily for contraception and an over-the-counter iron tablet. She has no known allergies. She does not smoke or drink alcohol. She smokes occasional marijuana that she says helps her sleep. She is a competitive swimmer who competes in the local public swimming squad twice a week. She is vegetarian and drinks one cup of instant coffee a day.

On examination, Hayley looks well. Her temperature is 36.7 °C, blood pressure is 109/74 mmHg, heart rate is 64/min and body mass index is 21 kg/m2. The remainder of her examination is normal.

The nearest emergency department is 600 km away.

What would you advise Hayley about nutrition in pregnancy? Write four (4) specific pieces of nutrition advice.

Question 5

Hayley returns to see you at 16 weeks pregnant for the results of her combined first trimester genetic screening tests that were ordered by another GP. The results show that the risk of Down syndrome is reported at 1 in 50.

What further diagnostic investigation is appropriate? Write one (1) diagnostic investigation.

Question 6

Hayley is rushed into your clinic’s emergency room at 37 weeks pregnant by her partner. She explains that for the last two hours she has had continuous severe abdominal pain and some bright red vaginal bleeding. You perform an appropriate immediate examination and a nurse begins to take observations. While reviewing the records you see that Hayley’s pregnancy has had no other complications to date. Her bloods and antenatal care have all been appropriate and her blood group is A negative.

What immediate management actions are appropriate? Write five (5) immediate management actions.

Case 3: Bridget Mathieson

Question 7

Bridget Mathieson, aged 51 years, returns for results of investigations ordered one week ago as part of her work medical assessment. She has been well recently.

Bridget has a past medical history of hypothyroidism and major depression, for which she takes levothyroxine 50 μg orally daily and desvenlafaxine 100 mg orally daily. She does not smoke, drink alcohol or use recreational drugs. She has a family medical history of type 2 diabetes mellitus, with her father diagnosed at 67 years of age.

On examination, Bridget looks well. Her temperature is 36.6°C, blood pressure is 139/98 mmHg, heart rate is 78/min regular, respiratory rate is 15/min, oxygen saturation is 97% on room air, body mass index is 36.7 kg/m2 and waist circumference is 105 cm. The remainder of her examination is normal.

Bridget’s investigation results are shown below.

Full blood count: Normal

Urea and electrolytes: Normal

Thyroid function tests: Normal

Liver function tests

Test	Result	Normal range
Total protein	79 g/L	64–81
Albumin	46 g/L	33–46
Globulin	33 g/L	26–41
Alkaline phosphatase	101 U/L	20–105
Gamma-glutamyl transferase	127U/L*	5–35
Alanine aminotransferase	75U/L*	5–30
Aspartate aminotransferase	52U/L*	10–35
Lactate dehydrogenase	176 U/L	120–250
Bilirubin	6 μmol/L	3–15

Blood glucose (fasting)

Test	Result	Normal range
Fasting glucose	5.3 mmol/L	3.0–5.4
HbA1c	5.1 mmol/L (32%)	<6.0 (<42)

Lipid studies (fasting)

Test	Result	Normal range
Total cholesterol	5.7mmol/L*	<5.6

High-density lipoprotein	0.8mmol/L*	>1.0
Low-density lipoprotein	2.4 mmol/L	<2.5
Triglyceride	2.4mmol/L*	<1.5
Non-high-density lipoprotein cholesterol	4.9mmol/L*	<4.6
Low-density lipoprotein/high-density lipoprotein ratio	3.0	<3.7
Cholesterol/high-density lipoprotein ratio	7.1*	<4.5

What is the single most likely diagnosis to account for the abnormal investigation results? Write one (1) specific diagnosis.

Question 8

What additional initial investigations are appropriate? Select six (6) investigations from the following list.

A. Alpha-fetoprotein
B. Angiotensin-converting enzyme
C. Antinuclear antibody
D. Antimitochondrial antibody
E. Antismooth muscle antibody
F. Biopsy of liver
G. C-reactive protein
H. Coagulation studies
I. Colonoscopy
J. Complement components C3 and C4
K. Computed tomography scan of abdomen
L. Faeces for fat microscopy
M. Gastroscopy
N. Glucose tolerance test
O. Hepatitis A serology
P. Hepatitis B serology
Q. Hepatitis C serology
R. Iron studies
S. Lactate dehydrogenase
T. Serum calcium
U. Serum magnesium
V. Serum phosphate
W. Serum protein electrophoresis
X. Sweat electrolytes
Y. Transient elastography
Z. Ultrasound of abdomen

Question 9

Bridget’s additional investigations confirm the single most likely diagnosis, and she is managed appropriately.

Two months later, Bridget returns reporting a three-day history of a very painful, red left eye with associated blurring of vision and watering of the eye. One week ago, she left her soft contact lenses in overnight.

On examination, Bridget looks well, although uncomfortable. Her temperature is 37.1°C, blood pressure is 128/87 mmHg, heart rate is 72/min regular, respiratory rate is 13/min, oxygen saturation is 98% on room air and body mass index is 36.7 kg/m². You note the appearance of her left eye (see image). Her visual acuity is 6/6 in her right eye and 6/18 in her left eye. The remainder of her examination is normal.

What is the single most likely diagnosis? Write one (1) specific diagnosis.

Case 4: Susan Keilor

Question 10

Susan Keilor, aged 35 years, reports a four-month history of tiredness and difficulty concentrating. Initially, she attributed her symptoms to increased stress whilst completing a project at work, however her symptoms have continued despite completion of the project.

Susan has no significant past medical history and uses the levonorgestrel intrauterine contraceptive device for contraception. She has no known allergies. She does not smoke or drink alcohol. Her father died from an acute myocardial infarction, aged 65 years.

On examination, Susan looks well but tired. Her temperature is 36.9 °C, blood pressure is 110/65 mmHg, heart rate is 70/min and body mass index 28 kg/m2. The remainder of her examination is normal.

You arrange for Susan to have blood tests with results shown below.

Haematology

Full blood count is normal

Biochemistry

Urea, electrolytes, creatinine and fasting glucose levels are normal

Liver function tests

Liver function tests are normal

Thyroid function test

Test	Results	Normalrange
Thyroid stimulating hormone	8.9*mIU/L	0.35 – 5.5
Free thyroxine	4.2*pmol/L	9.0 – 25.0

Which investigation would confirm the most likely diagnosis? Select one (1) investigation from the following list.

Anti-nuclear antibodies
Beta human chorionic gonadotrophin
Biopsy of thyroid
C-reactive protein
Computer tomography scan of neck
Erythrocyte sedimentation rate
Parathyroid hormone level
Reverse triiodothyronine
Sestamibi thyroid scintigraphy
Thyroid peroxidase antibodies
Thyroid scintigraphy
Thyroid stimulating hormone receptor antibodies
Triiodothyronine free level
Ultrasound scan of thyroid

Question 11

The additional investigation confirms the most likely diagnosis.

What specific pharmacological management action is appropriate? Write one (1) specific pharmacological management action, including route and frequency.

Question 12

Susan is managed appropriately and her blood tests return to normal eight weeks later.

One year later, Susan presents with a four-month history of worsening fatigue. She says she has been feeling unwell and bloated at times and has an itchy rash on her shoulders, elbows, knees and abdomen (see image). She says she has been compliant with her medication and the results from her most recent blood test, performed one week ago, are shown below.

Thyroid function tests

Test	Results	Normalrange
Thyroid stimulating hormone	5.4 mIU/L	0.35 – 5.5
Free thyroxine	12.5 pmol/L	9.0 – 25.0

What investigations would help to determine the underlying cause of Susan’s symptoms? Select six (6) investigations from the following list.

A. Anti-endomysial antibodies
B. C-reactive protein
C. Deamidated gliadin peptide antibody
D. Double stranded DNA antibody
E. Erythrocyte sedimentation rate
F. Full blood count
G. Herpes simplex virus serology
H. Human leukocyte antigen B27
I. Iron studies
J. Liver function test
K. Punch biopsy for histopathology
L. Radioallergosorbent test
M. Serum calcium
N. Serum folate
O. Serum zinc
P. Swab for herpes simplex virus polymerase chain reaction
Q. Swab for microscopy, culture and sensitivities
R. Swab for varicella polymerase chain reaction
S. Tissue transglutaminase antibody
T. Vitamin B12

Case 5: Steven Mack

Question 13

Steven Mack, aged 73 years, presents with his wife, Sandra. They are both concerned about Steven’s overall wellbeing. Over the last few months, they have noticed that Steven has had significant difficulties with concentration and attention to the point where he cannot complete the crosswords that he used to enjoy. Sandra says he often seems to be confused, wondering where he is and what he is doing. Sandra

has noticed that sometimes Steven describes seeing their son in the room however their son has not visited for several years and lives in the United States of America. Sandra says that sometimes Steven can seem completely normal and at other times he seems distant and strange. Steven says that he has had difficulties picking up objects as his hands occasionally shake or his arms seem stiff.

Steven has a past medical history of hypertension, hypercholesterolaemia and stage 3b chronic kidney disease, for which he takes perindopril 4 mg orally daily and simvastatin 20mg orally daily. He is an ex- smoker of 10 pack-years having quit 30 years ago. He does not drink alcohol. He mobilises with a four- pronged cane.

On examination, Steven looks well. His temperature is 36.7 °C, blood pressure is 139/91mmHg, heart rate is 86/min and body mass index 25 kg/m2. The remainder of his examination is normal.

What are the most likely differential diagnoses? Write two (2) differential diagnoses.

Question 14

What initial investigations are appropriate? Select six (6) investigations from the following list.

A. Anti-nuclear antibody
B. Blood glucose level
C. Bone densitometry
D. C-reactive protein
E. Carcinoembryonic antigen
F. Computed tomography angiography of the brain
G. Computed tomography scan of brain
H. Electroencephalogram
I. Full blood count
J. Human immunodeficiency virus serology
K. Liver function tests
L. Prostate specific antigen
M. Serum amyloid
N. Serum calcium
O. Serum folate
P. Serum magnesium
Q. Serum protein electrophoresis
R. Thyroid function tests
S. Ultrasound scan of carotid arteries
T. Urea and electrolytes
U. Venereal disease research laboratory test
V. Vitamin B12
W. Vitamin D

Question 15

Steven’s investigation results are normal.

Two weeks later, Steven returns with Sandra. Sandra is very concerned as Steven’s behaviours are becoming worse. She says he has been increasingly confused and at times has been angry and agitated. She tells you that this occurs particularly when he cannot find his watch or his book in the afternoon. She says he often gets very angry and then cannot seem to settle for ‘hours’. Sandra asks for advice regarding what she can do to manage his behaviour.

What evidence based non-pharmacological interventions are appropriate to discuss with Sandra? Write four (4) non-pharmacological interventions.

Case 6: Max Johnston

Question 16

Max Johnston, aged 24 years, presents with an injury to his left wrist. He says he was opening oysters one hour ago when the knife slipped and cut him.

Max has a no significant past medical history and takes no regular medications. He has an allergy to amoxicillin which caused anaphylaxis previously. He received all of his childhood immunisations. He does not smoke and drinks six standard drinks of alcohol two nights per week. He is right hand dominant.

On examination, Max looks well. His temperature is 36.8 °C, blood pressure is 128/79 mmHg, heart rate is 88/min and body mass index is 22.5kg/m². He has a clean, deep, transverse 4 cm long laceration on the volar aspect of his left wrist, 3 cm proximal to the wrist crease. There is a slow ooze of blood and he is unable to flex the wrist or fingers.

What additional specific examination findings would suggest a deep laceration with more significant injury? Write four (4) additional specific examination findings.

Question 17

You refer Max urgently to the local emergency department.

Prior to transfer, what immediate management actions are appropriate? Write four (4) immediate management actions.

Question 18

Max’s wound was managed appropriately at the local hospital. He was discharged two days ago on a three-day course of clindamycin 600 mg three times a day and ciprofloxacin 400 mg twice daily.

Max presents today with an itchy rash over his trunk, arms, legs and face that started this morning (see image). Max denies light headedness, flushing, nausea, vomiting, abdominal pain or nasal congestion.

What specific additional features on history would suggest a serious underlying cause of Max’s rash? Write four (4) specific additional features on history.

Case 7: James Mathews

Question 19

James Mathews, aged seven years, presents to your rural clinic with his mother, Sarah, reporting a six- week history of a dry cough. Sarah says that James has been coughing most mornings and evenings and she has also noticed him stop to catch his breath at times when playing outside. COVID-19 was definitively excluded at the start of his illness.

James has no significant medical history, takes no regular medications and has no known allergies. His immunisations are up to date. The family have recently moved to rural South Australia from Brisbane.

On examination, James looks well. His temperature is 36.8 °C, heart rate is 90/min, respiratory rate is 14/min, oxygen saturation is 98% on room air, height is 122 cm, weight is 23 kg and body mass index is

15.5 kg/m2 (50th centile). Examination of his chest reveals scattered mild end-expiratory wheeze. The remainder of his examination is normal.

You decide to commence appropriate pharmacological management.

Apart from prescribing appropriate medications, what management actions are appropriate? Write three (3) management actions.

Question 20

Three weeks later, James is brought into your practice by his parents with difficulty breathing. Your practice is located next to the local soccer fields and James developed difficulty breathing playing in his first soccer match this morning.

On examination, James appears well but quiet. His temperature is 37.1 °C and heart rate is 95/min. Examination of his chest reveals a mild wheeze bilaterally.

What additional specific findings on physical examination would suggest that James requires hospital admission? Write four (4) specific additional physical examination findings.

Question 21

You arrange to transfer James to the nearest emergency department via ambulance.

Prior to transfer, what immediate management actions are appropriate? Write three (3) immediate management actions. If your answer includes medications include route and frequency. Dosages are not required.

Case 8: Caroline Hews

Question 22

Caroline Hews, aged 51 years, presents to your clinic requesting a repeat opiate script. You have never met Caroline but you are aware that her regular GP, who works in the same clinic, will be uncontactable for two months. You have access to her full medical record.

Caroline has a past medical history of L3/4 spinal fusion surgery three years ago and she has had appropriate rehabilitation. She has been seen by a multidisciplinary pain clinic, including a pain specialist, with whom she has been fully compliant. Despite these efforts, she continues to require oxycodone sustained-release 20 mg orally twice daily and pregabalin 75 mg orally nocte. She has no known allergies or adverse effects from her medications. She says her mood is normal. She does not smoke or drink alcohol.

On examination, Caroline looks well. Her temperature is 36.9 °C, blood pressure is 134/91 mmHg, heart rate is 74/min and regular, respiratory rate is 14/min, oxygen saturation is 98% on room air and body mass index is 24 kg/m2.

Prior to supplying a prescription, what immediate management actions are appropriate? Write five (5) immediate management actions.

Question 23

Two days later you are contacted by a local police officer. The police suspect that Caroline’s partner has been stealing her opiates and using them recreationally. They would like information regarding Caroline’s recent appointments and her prescription history.

What immediate management actions are appropriate? Write two (2) immediate management actions.

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