Dr. Heggarty and Dr.

Teague say common things are common and when you hear hoof beats outside your GP practice,
think HORSES, not ZEBRAS. This is so true and keep this in mind when you study, especially as it gets so close to
exams! Also, every system that you study in 4th year will be tested without fail in the KFP and OSCEs combined so
please do not neglect going through certain areas in preparation for exams. Even, family studies, MTA, CTA and
professionalism portfolio all come up so please go through that.
Our KFP was worth 136 marks (125 clinical (Talley & CLIX) + 11 pathology). Our KFP was as follows:

1) Case of right lower lobe pneumonia - > they first asked you to explain the chest x-ray findings in a right lower lobe
pneumonia (make sure you have a systematic approach to analyzing, interpreting and commenting on chest x-rays).
You were then asked for the signs and symptoms that you may expect in this patient. Remember symptoms are the
patient’ subjective report of how they are feeling e.g. lethargy, fatigue, SOB whereas signs are subjective reports of
what the patient is experiencing e.g. tachycardia, tachypnea, increased vocal fremitus, dullness on percussion etc. We
were then asked to provide 6 investigations for this patient apart from the chest x-ray that has been provided. You
had to give a rationale for each. Gone are Years 1-3 where you can say FBC, U&E’s, LFT’s for everything, you need to
have a clear and logical rationale for every single investigation you do and you have noticed that clinically in your
hospital rotations this year. We also got asked to assess the severity of pneumonia (know one of the severity scoring
tools really, really well -> CURB65, SMARTCOP, Pneumonia Severity Index Scoring Tool). With this patient, we were
told that he now presented with haemoptysis later on in the admission and they asked as what are the two most
common conditions or diseases you need to think of, use common sense and don’t over-read the question -> all they
wanted was lung malignancy and TB, some people put down bronchiectasis, cystic fibrosis which is right, but not the
two most serious, logical things you think of when you think of haemoptysis. They also asked two first line
investigations if you are thinking malignancy and TB. There was also a question about first line management of this
patient -> e.g. whether to admit or not, whether to give fluids, IV antibiotics, obs etc.

2) Case of STI’s – we were given a case of painful genital ulceration -> was Herpes and they asked for 2 differentials ->
so syphilis, donovanosis. Just read about LGV and keep that in mind for these upcoming exams. You have to
remember that STI’s travel in packs and the next question asked us what are the notifiable STI’s in Australia - >
chlamidya, gonorrhea, syphilis, Hep B & C, HIV. You had to know the first line investigations for each of these. They
then asked a question about how to reduce rates of STI’s from a public health perspective, so things like improving
education, using condoms etc.
3) Classic JCU case of RHD – they then said this patient had a pan-systolic murmur best heard in the mitral area with
the diaphragm of the stethoscope and radiating to the axilla and there was a concomitant mid-diastolic murmur with
an opening snap and best heard in the mitral area with the bell of the stethoscope. So, you had to work out from this
that the patient had MR and MS and you had to draw the murmurs out (in other words S1 -------→ A2 P2 ----→S1).
They also had a 25 box ECG strip with showed an irregularly irregular pattern with non-discernible P waves and
tachyarrythmic. It was Atrial Fibrillation. However, the next question asked us to calculate the rate of this rhythm and
a lot of people got this wrong. So, I will explain how to calculate rate in an irregular rhythm ECG. So, in a normal 50
box ECG strip, if we have an irregular rhythm, we count the number of QRS complexes and multiply this by 6 but do
you know why? So, in a normally calibrated ECG, each small square represents 0.04 seconds and therefore one large
square (which has 5 small squares), this equates to 0.2 seconds. Therefore, 5 large boxes horizontally equates to 1
second. And, as there are 50 boxes on a normally calibrated ECG strip, this equates to 10 seconds. Hence, to work out
the rate/min, we count the number of QRS complexes and multiple by 6. So, if you have 25 box strip and you know
that 5 large boxes horizontally equates to 1 second, then you have 5 second strip and so to calculate rate, you will
need to count the number of QRS complexes and multiply by 12. Hope this makes sense and I haven’t confused you.
We also had questions in this case about the pathophysiology of A.Fib in someone with MR and MS. The next question
asked us about the pathophysiology of pulmonary oedema, pulmonary hypertension and SOB in this patient. So, you
had to go back to Year 2 cardio. and resp. physiology with all of your back logging of pressures and Starling’s forces to
arrive at your answer.

4) There was a neuro case where we were given a photo of a man with only unilateral forehead sparing and the wife
comes to you concerned that her husband has had a stroke. You have to respond to the wife’s concerns. So, basically,
what you had to say to the wife is that in a stroke, as it is a UMN lesion, there will be forehead sparing as the facial
nerve in an UMN lesion still has bicortical representation. However, what the man most likely had was an idiopathic
LMN lesion of his facial nerve (Bell’s palsy, different to Bell’s phenomenon). In a LMN lesion, there is no bicortical
representation and so you don’t get forehead sparing in the affected side. You also were asked for differentials for
facial nerve palsy and questions you would ask accordingly. So things like trauma, Ramsay Hunt syndrome and Frey
syndrome would have been acceptable. However, as there was facial nerve palsy, you had to ask questions about
hyperacusis due to stapedius nerve palsy and crocodile tears.

5) We had a case about post-menopausal bleeding -> the main things you want to rule out are endometrial
adenocarcinoma and cervical cancer but the most common cause is atrophic vaginitis. Other differentials are
endometrial hyperplasia, endometrial polyps, cervical polyps etc. You had to ask history-taking questions regarding
family history of endometrial cancer, constitutional malignancy symptoms etc. In the end, we were given a
microscopic image of well-differentiated endometrial adenocarcinoma and they asked for 3 microscopic features (you
need to mention things like pleiomorphism, gland-like structures, nuclear to cytoplasmic asynchrony etc. (Don’t
neglect Term 4 pathology)

6) We had a case about the acute abdomen. In the end of it was acute pancreatitis but you had to have solid
differentials such as peptic ulceration, AAA, cholecystisis, appendicitis and ectopic pregnancy etc. The differentials you
formulate are dependent on the age and gender of the patient. Keep that in mind. Also, please make sure you read
the KFP question stem because in our case, it said that the patient had an appendicectomy and cholecystectomy so if
you put appendicitis and cholecystitis as differentials, then it shows you didn’t read the stem carefully enough. Know
the causes of acute pancreatitis (remember the mnemonic GET SMASHED from Oxford Handbook of Clinical
Medicine) and also know hot to assess the severity of acute pancreatitis (different scoring systems are available but
the modified GLASGOW scoring tool in the Oxford handbook is excellent. Acute abdomen is likely to come up so know
how to take a focused history, do an appropriate examination, run investigations (with rationale) and have a first-line
management plan ready.

7) There was a case of metabolic syndrome - > know the five components (low HDL, high triglycerides, BP, waist
circumference, insulin resistance). There was an ECG of a high lateral wall MI and you had to comment on the ECG.
Something that is being used more and more clinically these days especially in GP settings is the Australian Absolute
Cardiovascular Risk Calculator, make sure you know what this this is!

8) There was a case of diabetic nephropathy leading to uraemia - > you had to know how to diagnose T2DM (make
sure you know current diagnostic protocols), we then were provided with a classic nodular glomeruolsclerosis
microscopic image with KW lesions and hyaline arteriolosclerosis (basically the question asked about the microscopic
features), in terms of the uraemia, you had to know what questions to ask on history and know complications e.g.
uraemic encephalopathy, haemorrhagic pericarditis, hiccups, IHD, GI bleeding, sallow skin, band keratopathy, uraemic
frost. Know the different stages of CKD from 1-5, along with eGFR values. Also know the 3 main causes -> T2DM,
hypertension, chronic glomerulonephritis.

9) There was a case of a middle-aged Caucasian male presenting to GP due to complaints of fatigue, lethargy. GP did a
blood test which showed a microcytic, hypochromic iron deficiency anaemia. THIS IS COLON CANCER UNTIL PROVEN
OTHERWISE. YOU NEED TO REMEMBER THIS! Colonoscopy is next on the list. There was a peripheral blood smear of
severe iron deficiency anaemia (microcytosis, pencil and cigar poikilocytosis, anisocytosis, reactive thrombocytosis
etc.) You have to know what questions to ask on history in a patient presenting like this and be able to have a
differential diagnosis on board. So, for eg. if the presenting complaint was PR bleeding with fatigue, apart from ruling
out colonic carcinoma, other differentials would be haemorrhoids, diverticular disease or even angiodysplasia. While I
am on this point, I’d like to remind you about something. So, say you have a 54 year old caucasian patient who goes
into his GP for fatigue lethargy and in the end the GP does a series of blood tests which show iron deficiency anaemia,
you automatically have to think that this case is colon cancer till proven otherwise right, so if you were asked to do an
examination, you would say something along the lines of this ..... hi, my name is so and so (WASH HANDS), I'm a 4th
year medical student, I've been asked to come and examine you regarding your complaint of fatigue and lethargy. You
then look at the doctor and say in this case, i need to rule out colon cancer causing iron deficiency anaemia and hence
I will be doing both a gastrointestinal and haematological examination primarily. If I have time at the end of these
examinations, I will also do a cardiovascular examination to look for a flow systolic murmur as well as PR examination
...... then you proceed with the examination. You see, by doing this, even if you do run out of time during the 8
minutes, then the doctor marking will know your thought process ..... make sure you also ask for consent from
patient, adequate exposure, positioning etc ....

10) The last case was a post-menopausal woman on HRT with osteoporosis who had fallen down and suffered an
intra-trochanteric fracture. You could not make out shenton’s line in this x-ray. The question asked about the
pathophysiology of osteoporosis (they wanted a very detailed answer so make sure you go through this right from the
very basics), they wanted to know about the risk factors (follow the SHATTERED mnemonic in Oxford Clinical
Handbook of Medicine) as well as the management (you have to think holistic and multi-disciplinary when it comes
down to osteoporosis management). They then asked 4 advantages and 4 disadvantages of HRT.

In terms of the OSCE, we had 9 live stations (1 long station) and 3 rest stations. They were as follows:

1) An elderly gentleman presents to you with left sided lower quadrant abdominal pain, this was all that was
given to you in the stem outside the OSCE room, you had to do a focused history, ask for examination finds, do a set
of investigations and then complete a first-line management plan (e.g. admit vs send home, fluids, antibiotics,
analgesia etc.). You need to have a good set of differentials from most common to least common and rule out serious
pathology. In this case, it was acute diverticulitis on a B/G of chronic constipation.

2) Family Studies Station – 12 month old child coming in for immunisations! Know the latest immunisation
schedule unless you are told not to haha. At 12 months, it is MMR, Hib, Men C. The mum then goes onto to tell you
about a friend’ child who got autism from MMR and asks you about this. So, it’s your job to tell her the facts regarding
this and dispel the common immunisation myth.

3) Classic case of primary hypothyroidism (low T3, low T4, high TRH, high TSH). You have to go in and do an
examination for hypothyroidism on a woman and then you have to explain to the patient how levothyroxine works in
a manner that the patient can understand.

4) Emergency Resuscitation Station -> you walk in and there is a doctor and mannequin. You have to basically go
through First Aid, so DRSABCD. While you are checking for airway, you will be asked to insert a Guedel’ airway in.
Make sure you know what an OPA and NPA are as well as the indications and contraindications for each of these. You
also had to demonstrate adequate bag valve masking. After this, you had to perform effective CPR (Remember that it
is 30 compressions and 2 breaths, however the doctor helps you and does the bag valve masking for 2 breaths - >
make sure you know how to do compressions well by going 1/3 of the way into the chest! Practise, practise, practise
with friends! I know people who failed this station just because of that! Also, remember that you are roughly aiming
for 100 compressions/min and so that will dictate how fast you go. You are then stopped whilst you are doing your
primary survey and asked about an AHD and EPOA. You had to define both of these, know the difference between
these and also list several advantages and disadvantages for both. This was where our professionalism portfolio stuff
came in.

5) Resp station – we had a history stem outside the room and a chest x-ray which we had to interpret before
walking into the room. You had to analyse both and perform a focused examination! The history was a 60 year old
Caucasian gentleman with a 50 pack year history presents to his GP with worsening dry cough and SOB. A chest x-ray
was done by the GP, which was what you had to analyse. It showed a unilateral right-sided pleural effusion with a
meniscal level and loss of the right costo-phrenic angle. You have to then and there think that this case is most likely a
lung malignancy causing a right-sided pleural effusion. People who just did a general non-focused resp. exam got 50%.
Those who did a pleural effusion examination got 75%. Those who did a malignancy causing pleural effusion
examination had the chance to get 100%. Make sure you adequately expose the patient. In this case, when you
politely asked the patient to remove their t-shirt, you could see a mark on the right lateral chest where the chest drain
was inserted.

6) Rheumatoid Arthritis Hand Examination station -> this was a patient with actual RA and so if you walk in and
say on general inspection, there is no asymmetry, no visible deformities, no Z-deformity, no swan neck deformity and
function is fine, you fail the station. JCU intentionally selected RA patients in the community (whether you are in
Townsville or Cairns) for this OSCE station! You also had to interpret the hand x-ray for that patient. Interestingly, it
showed a mixed RA & OA picture - > non-uniform joint space narrowing, bony cysts, subchondral sclerosis,
osteophytes or bony spurs, juxta-articular osteopenia, erosive inflammatory damage surrounding joint etc.

7) Long Case (I don’t think you have this anymore in your OSCE but it’s good to know about I think) -> All we had
was a female presents with acute SOB and right sided chest pain. ECG was done and you had to interpret it before
going into the room. The ECG showed sinus tachycardia, that was it. You had to take a focused history, perform an
appropriate, focused examination, come up with initial investigations and also outline a feasible management plan. In
the end, the woman had calf pain and chest pain and had a family history of anti-phospholipid syndrome that you had
to elicit. So, the presentation was PE and remember that sinus tachycardia is the most common presentation finding
on an ECG for PE, not S1Q3T3, that’s very rare.
8) PSA discussion station - > patient with a family history of prostate cancer comes in and has a PSA test done
which is quite high. He then asks you what he needs to do. Basically, you needed to refer back to the RACGP Red Book
screening guidelines regarding prostate cancer and say there is not very good sensitivity and specificity and say there
is a lack of evidence pertaining to morbidity and mortality from doing these tests following high PSA and also mention
side effects of doing further tests such as impotency etc. Go through your RACGP red book and look at smoking,
nutrition, alcohol, physical activity as well as all the major cancers.

9) CTA Breast Examination station – this was a breast examination in a woman who was complaining of a breast
mass and had a family history of breast cancer. You had to do a complete breast examination as done exactly in CTA.
Don’t forget to ask for consent at the beginning, don’t forget the chaperone (the marker says they will be chaperone
when you ask), don’t forget to adequately cover the patient up before explaining findings, do a well woman’s check,
do a quick history about the breast mass and family history of breast cancer, also recommend how often she needs to
do self examination of the breast, how often to go to the doctor etc. (all this information will be in the RACGP red
book).

MCQ

There was a lot of pathology and microscopic images here. There was surprisingly a lot of Term 4 pathology in the
MCQ, which took us all by surprise as most of us had been focusing on Terms 1-3 and slightly neglected Term 4 haha.
So, make sure you go through that. While there was a lot of microscopy, there was a large clinical stem in most
MCQ’s, which meant that if you had good clinical acumen, you should be fine to get the answer even without the
microscopic images. There was a lot of CLIX-type questions as well so don’t forget to revise CLIX if you haven’t done so
already.