Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated 4 Category 2 points (Activity ID: 9606).
Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014–16 triennium; therefore, the previous months answers are not published.
Single completion items
DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.
Case 1: Fleur Melville
Fleur Melville, aged 42 years, has presented to you on multiple occasions over the past 6 months with a variety of non-specific symptoms. She is becoming increasingly worried that she has a serious condition such as cancer.
Which of the following is TRUE regarding cancer presentations in general practice?
- Less than one-quarter of cancers will present with classic alarm symptoms.
- On average, GPs diagnose cancer 3–4 times per year.
- Patients with breast cancer are more likely to have had multiple visits to the GP prior to referral than patients with lung cancer.
- Repeat visits with the same symptom are a potential ‘red flag’ for cancer.
- All of the above.
Which of the following is TRUE regarding cancer risk assessment tools?
- On a CAPER chart, a positive predictive value of greater than 2% requires urgent review.
- QCancer models have potentially greater clinical relevance than CAPER charts.
- On a CAPER chart, if a patient presents with the same feature twice the positive predictive value of that feature remains the same.
- QCancer provides positive predictive values for specific cancers based on single and pairs of symptoms, signs and common investigations.
- An advantage of CAPER charts is that they take account of age, family history and smoking.
Fleur is worried about her risk of lung cancer as she was exposed to passive smoking in her house as a child. On the basis of a CAPER chart for risk of lung cancer, which of the following combinations of features is associated with a positive predictive value (PPV) of >5%?
- Thrombocytosis and loss of weight
- Cough and chest pain
- Haemoptysis and cough
- Loss of weight and fatigue
- Loss of appetite and dyspnoea
After further assessment, you are able to reassure Fleur she does not have lung cancer. Two weeks later, she presents to you after reading a magazine article about a woman who went to her GP many times with similar symptoms as herself before she was eventually diagnosed with ovarian cancer. According the CAPER charts for risk of ovarian cancer, which of the following combinations of features is associated with a PPV of >5%?
- Abdominal bloating and abdominal pain
- Urinary frequency and abdominal distension
- Presenting with loss of appetite on more than one occasion
- Abdominal pain and loss of appetite
- Abdominal distension and loss of appetite
Case 2: Rosa Corletti
Rosa Corletti is 38 years of age and has recently had curative treatment for breast cancer.
Which of the following is FALSE regarding the issues that commonly affect breast cancer survivors?
- They are more likely to experience sexual dysfunction.
- They are more likely to experience premature menopause.
- They are at lower risk of developing diabetes.
- They are at higher risk of osteoporosis.
- They are at higher risk of cardiomyopathy if they have had anthracycline treatment.
Which of the following is NOT a goal of the chronic disease model of cancer?
- Surveillance for cancer spread, recurrence or second cancers.
- Documentation of care in a patient-held record.
- Prevention of recurrent and new cancers, and of other late effects.
- Coordination between specialists and primary care providers.
- Intervention for the consequences of cancer and its treatment.
Which of the following would be appropriate management of Rosa according to the guidelines regarding breast cancer recurrence surveillance?
- History and examination every 2 months for the first 2 years
- Bone scanning only if clinically indicated
- Mammography every 2 years
- Annual ultrasound of regional lymph nodes
- PET scanning every 5 years
Which of the following should be part of the GP’s role in Rosa’s ongoing care?
- Assessment of the impact of her cancer and treatment on her relationships
- Assessment of medication compliance
- Assessment of osteoporosis risk
- Examination for signs of lymphoedema
- All of the above
Case 3: Reg Burrows
Reg Burrows is 83 years of age and has advanced metastatic prostate cancer. Although he is functioning reasonably independently now, you anticipate that his health will decline at some stage in the near future.
Regarding GP care of Reg, which of the following is TRUE?
- Reg is likely to have very complex palliative care needs, which will exceed the skills of most GPs and require extensive specialist management.
- Reg is likely to be difficult to manage in a general practice setting because the burden of disease and time course of disseminated cancer are unpredictable.
- Low continuity of care for patients like Reg increases the likelihood of emergency department visits in the last 6 months of life by 50%.
- Active GP involvement in Reg’s palliative care would increase the likelihood that he will die at home.
- All of the above are true.
You would like to be involved in Reg’s palliative care delivery and use the PEPSI COLA framework to assist in your planning. All of the following are domains in the PEPSI COLA framework for palliative care planning, EXCEPT:
You are concerned about Reg’s ongoing care when you are not in the clinic. Which of the following strategies can be used to improve continuity of care outside your working hours?
- Offering Reg and his carers a telephone contact number
- Informing Reg of your practice’s after hours arrangements
- Providing a written health summary for Reg to have at home to assist other visiting doctors
- Informing locum services of Reg’s palliative status
- All of the above
After discussion with Reg, you contact the local community palliative care service to enlist their support in his further care. Evidence has shown that coordination of care between GPs and specialist palliative care services:
- Improves patients’ quality of life in the last week of life
- Results in temporary functional improvements in patients
- Reduces hospital admissions by 30%, compared with normal care
- Achieves all of the above
- Achieves none of the above
Case 4: Ivan White
Ivan White is a retired GP aged 68 years. His wife died last year after a prolonged hospital stay following an unexpected stroke. As her next of kin, Ivan had to make many decisions about his wife’s medical care on her behalf, and found it very difficult as he was uncertain of what her preferences would have been. He would like to avoid putting his children in the same position in the event he is no longer able to make decisions for himself. You discuss with him the option of completing an advanced care directive (ACD).
All of the following are true regarding ACDs, EXCEPT:
- They are recognised by common law or authorised by legislation.
- They must be signed by a competent adult.
- They are formal records of advanced care plans.
- They may not appoint a substitute decision-maker to make decisions about health care.
- They record a person’s preferences for future care.
Which of the following statements is CORRECT regarding the Code of Ethical Practice for ACDs?
- Autonomy should not be influenced by a person’s culture, background, history or spiritual and religious beliefs.
- Adults should not be presumed competent.
- Directions in an ACD apply to a specific concept of health.
- The reasonable person test is used to decide what constitutes quality of life.
- A valid ACD that expresses preferences or refusals relevant and specific to the situation at hand must be followed.
Ivan invites you to participate in a debate next week at a retired doctors group function. The topic is ‘Advanced care directives are a waste of time’. You are on the affirmative team. Which of the following arguments could you use to support your case?
- ACDs lack validity because the person making it may lack the information required to make an informed choice.
- ACDs lack efficacy because they may not provide sufficient clarity to guide clinical management.
- ACDs lack durability as a person’s treatment choices may change over time
- ACDs may be difficult to access when needed.
- All of the above.
Ivan is planning to travel around Australia in his caravan over the next year and wants to know if his ACD will be valid in other states. Which of the following is currently TRUE regarding the legislative restrictions that have been enacted governing ACDs in different jurisdictions?
- In the ACT, ACDs are only effective when the person is in the terminal phase of an illness.
- In WA, there are no restrictions.
- In NSW, directions in ACDs to withhold/withdraw life-sustaining measures cannot operate unless there is no chance of the patient regaining capacity.
- In VIC, ACDs do not cover procedures that would be considered palliative.
- In TAS, ACDs are only effective if the person is in a persistent vegetative state