CASE INFORMATION

Case ID: CCE-2025-005
Case Name: Mark Robertson
Age: 54 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K89 (Syncope), K99 (Cardiac arrhythmia NOS), N17 (Vasovagal episode)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their ideas, concerns, and expectations. 1.2 Develops a respectful and empathetic doctor-patient relationship. 1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including systemic and red flag symptoms. 2.2 Selects and interprets appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings. 3.5 Identifies red flag symptoms requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates a safe and evidence-based management plan. 4.3 Provides appropriate follow-up and monitoring.
5. Preventive and Population Health	5.2 Addresses modifiable risk factors for cardiovascular disease and syncope.
6. Professionalism	6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements	7.1 Orders appropriate tests in accordance with MBS guidelines.
9. Managing Uncertainty	9.2 Develops a plan for a patient with an unclear diagnosis.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on life-threatening conditions.

CASE FEATURES

Middle-aged male presenting with a recent episode of fainting.
No prior history of syncope or seizure disorder.
The episode occurred while standing in a queue at a supermarket.
Reports feeling lightheaded and nauseous before collapsing.
No history of head trauma, seizure activity, or confusion post-event.
Concerned about whether this could be a heart-related issue, low blood pressure, or something serious.
Requires clinical reasoning to differentiate between vasovagal syncope, cardiac arrhythmias, orthostatic hypotension, and neurological causes.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Discuss your differential diagnosis with the patient.
Explain the investigations you will request and why.
Provide an initial management plan and follow-up advice.

SCENARIO

Mark Robertson, a 54-year-old male, presents to your clinic after experiencing a fainting episode two days ago. He was standing in a queue at the supermarket when he suddenly felt lightheaded, nauseous, and sweaty before losing consciousness for a few seconds. He was helped by bystanders and regained consciousness quickly.

He is worried this might be something serious, like a heart problem or stroke, and wants to know what needs to be done.

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Robertson
Age: 54 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5 mg daily (Hypertension)
Atorvastatin 20 mg daily (Hyperlipidaemia)

Past History

Hypertension (diagnosed 10 years ago)
Hyperlipidaemia (diagnosed 8 years ago)
No prior history of syncope, arrhythmia, or seizures

Social History

Works as a sales manager, often on his feet.
Former smoker, quit 15 years ago (20 pack-year history).
Drinks 2-3 standard drinks per week.

Family History

Father: Died at 65 from a heart attack.
Mother: Alive, hypertension and type 2 diabetes.
No family history of epilepsy or sudden cardiac death.

Vaccination and Preventative Activities

Up to date with vaccinations.
Last health check one year ago.

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I passed out the other day while waiting in line at the supermarket, and I have no idea why. It really scared me.”

General Information

(Freely Shared if Asked Open-Ended Questions)

The fainting episode happened two days ago while you were standing in a queue at the supermarket.
You felt lightheaded, sweaty, and nauseous just before losing consciousness.
You woke up within a few seconds, and your wife and some bystanders helped you sit down.
You were aware of what was happening immediately after regaining consciousness and felt fine after a few minutes.
You had not eaten for about five hours before the episode.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

You had no pain or discomfort in your chest, arms, jaw, or back before or after the episode.
You had no convulsions, jerking movements, tongue biting, or loss of bladder control.
You did not experience confusion after waking up.
You have been feeling more tired than usual over the past few weeks but thought it was just due to work stress.
You have had no fever, diarrhoea, or recent illness.
You have never fainted before and have no history of seizures, strokes, or heart problems.

Symptoms and Triggers

The episode happened after you had been standing for about 15 minutes.
You felt warm and a little sweaty before passing out.
You have noticed occasional dizziness when standing up quickly, but never to this extent.
No blurred vision, slurred speech, or weakness on one side of your body.
No sudden headaches or neck stiffness.
No palpitations or irregular heartbeats before fainting.
No history of migraines.

Lifestyle & Risk Factors

Former smoker, quit 15 years ago after 20 pack-years.
Drinks 2-3 standard drinks per week, mainly on weekends.
Eats relatively healthy, but sometimes skips meals when busy.
Works as a sales manager, often on his feet, but has been feeling more fatigued than usual lately.
Takes amlodipine and atorvastatin daily but hasn’t checked blood pressure at home in a while.
No family history of epilepsy or sudden cardiac death.
Father died of a heart attack at 65.

Emotional Cues & Concerns

You were shaken by the experience and are worried it might happen again.
You are afraid this could be a sign of a serious heart issue, like a heart attack or stroke.
You don’t want to stop working but wonder if this means you should make changes.
You are concerned about whether you should stop driving until this is sorted out.
You are nervous about undergoing tests but want to be sure it’s nothing serious.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Is this serious? Could it be a heart problem?”
“What tests do I need? Should I be going to the hospital?”
“Could this happen again? What should I do if it does?”
“Should I stop driving or working until we know what’s going on?”
“Is my blood pressure medication causing this?”
“What are the chances that this was something like a mini-stroke?”
“Could this be low blood sugar? Should I be eating more regularly?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel relieved but still slightly anxious.
You might ask for clarification on the next steps:
- “So, you think it’s more likely something like a blood pressure drop than a heart problem?”
- “And if I follow your plan, I should be okay?”
You agree to the investigations and follow-up plan.

If the Candidate is Unclear or Dismissive:

You become more anxious and insist on further testing.
You might push for urgent tests or a cardiologist referral:
- “I just don’t want to take any chances. Can we do all the tests now?”
- “If this happens again, should I go straight to the hospital?”
- “I need to know for sure what’s going on.”

Ending the Consultation

If the Candidate Has Done Well:

You feel somewhat reassured and agree to the plan.
You might still confirm:
- “So, I should come back in a week unless something changes?”
- “You’ll call me when the test results are in?”
You thank the doctor and leave with a clear idea of what to do next.

If the Candidate Has Not Addressed Your Concerns Well:

You remain doubtful and uneasy.
You may say:
- “I think I might get a second opinion. I just want to be sure.”
- “I’m still not sure if this is something serious.”
You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including red flag symptoms and relevant risk factors.

The competent candidate should:

Use open-ended questions initially and then proceed with targeted questions to clarify the fainting episode.
Establish the circumstances of the event: onset, duration, prodromal symptoms (lightheadedness, nausea, sweating), post-event recovery.
Identify red flag symptoms, such as chest pain, palpitations, breathlessness, sudden severe headache, focal neurological deficits, or confusion post-event.
Differentiate between cardiac syncope (arrhythmias, structural heart disease), reflex syncope (vasovagal, situational), and orthostatic hypotension.
Ask about medications, particularly antihypertensives, as potential contributors.
Assess cardiovascular risk factors, including hypertension, hyperlipidaemia, diabetes, smoking history, and family history of sudden cardiac death.
Determine whether there have been previous fainting episodes or other unexplained collapses.
Evaluate neurological symptoms to rule out seizures or transient ischaemic attacks (TIAs).
Address the patient’s concerns, especially regarding heart disease or stroke.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain that syncope has multiple potential causes, some benign and some requiring further investigation.
Discuss most likely differentials:
- Vasovagal syncope: Common, often triggered by prolonged standing, dehydration, or emotional distress, with prodromal symptoms.
- Cardiac arrhythmia: Can cause sudden syncope without warning. Needs ECG and Holter monitoring.
- Orthostatic hypotension: Due to medication (e.g., antihypertensives), dehydration, or autonomic dysfunction.
- Neurological causes (TIA, seizure): Less likely due to absence of focal symptoms and post-event confusion.
Reassure the patient that fainting is often benign but requires appropriate assessment to rule out serious causes.

Task 3: Explain the investigations you will request and why.

The competent candidate should:

Justify initial investigations, including:
- ECG: To check for arrhythmias, prolonged QT, or conduction defects.
- 24-hour Holter monitor: If symptoms are intermittent and ECG is normal.
- Blood pressure (lying and standing): To assess for orthostatic hypotension.
- Full blood count (FBC), electrolytes, and glucose: To rule out anaemia, dehydration, or metabolic causes.
- Echocardiogram: If structural heart disease is suspected.
- Carotid Doppler ultrasound: If TIA is suspected.
Explain that if cardiac syncope is suspected, urgent referral to a cardiologist is required.
Provide a clear plan for test results review and next steps.

Task 4: Provide an initial management plan and follow-up advice.

The competent candidate should:

Develop a management plan tailored to the suspected cause:
- If vasovagal syncope is likely: Encourage hydration, slow position changes, and avoidance of triggers.
- If medication-induced hypotension is suspected: Consider dose adjustment or alternative medications.
- If cardiac arrhythmia is suspected: Arrange urgent cardiology review and monitoring.
Provide safety-netting advice, instructing the patient to seek urgent care for recurrent episodes, chest pain, syncope while seated or lying down, or prolonged unconsciousness.
Discuss driving restrictions in accordance with Australian guidelines (syncope may require temporary suspension of driving).
Arrange a follow-up appointment within a week to review test results and assess symptom progression.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, distinguishing benign vs serious causes of syncope.
Identifies red flags that require urgent referral.
Explains the differential diagnosis clearly, focusing on vasovagal, cardiac, and neurological causes.
Orders appropriate investigations, ensuring a structured diagnostic approach.
Develops a safe management plan with clear follow-up and safety-netting.
Provides reassurance while addressing patient concerns regarding heart disease and stroke.

PITFALLS

Failure to elicit red flag symptoms, leading to missed serious causes (e.g., arrhythmias, structural heart disease).
Over-reassurance without investigations, which could delay the diagnosis of a high-risk condition.
Omitting a cardiovascular risk assessment, particularly in a patient with hypertension and family history of heart disease.
Not considering medication side effects, particularly antihypertensives contributing to orthostatic hypotension.
Lack of clear safety-netting advice, leaving the patient unsure when to seek urgent medical attention.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets relevant history, including red flags.
2.2 Selects and justifies appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on history and findings.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and safety-netting.

5. Preventive and Population Health

5.2 Addresses modifiable risk factors for cardiovascular disease and syncope.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate tests in line with MBS guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on potentially serious conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD