Case Information
- Case ID: AF-021
- Patient Name: John Mitchell
- Age: 72
- Gender: Male
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: K78 – Atrial Fibrillation/Flutter
Competency Outcomes
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | Explaining atrial fibrillation (AF) in an understandable manner and addressing patient concerns |
| 2. Clinical Information Gathering and Interpretation | Taking a structured history and performing a cardiovascular examination to assess AF and risk factors |
| 3. Diagnosis, Decision-Making and Reasoning | Confirming the diagnosis, assessing stroke risk, and determining need for anticoagulation |
| 4. Clinical Management and Therapeutic Reasoning | Developing an appropriate management plan, including rate/rhythm control and anticoagulation |
| 5. Preventive and Population Health | Addressing modifiable AF risk factors (e.g., hypertension, lifestyle changes) |
| 6. Professionalism | Providing patient-centred, ethical care and discussing risks/benefits of treatment options |
| 7. General Practice Systems and Regulatory Requirements | Ensuring appropriate documentation, referral, and adherence to anticoagulation guidelines |
| 9. Managing Uncertainty | Recognising when cardioversion or specialist input is required |
| 10. Identifying and Managing the Patient with Significant Illness | Identifying complications such as heart failure or embolic events |
Case Features
- Concerned about whether he has a heart condition and what treatments are available.
- 72-year-old male presenting with palpitations and fatigue for the past 3 months.
- Describes occasional shortness of breath on exertion but no chest pain or syncope.
- Known hypertension (on perindopril 5 mg daily).
- Recent dizziness when standing but no history of falls.
- No known history of stroke, TIA, or heart failure.
Instructions
The candidate is expected to review the following patient record and scenario. The examiner will ask a series of questions based on this information. The candidate has 15 minutes to complete this case.
The approximate time allocation for each question:
- Question 1: 3 minutes
- Question 2: 3 minutes
- Question 3: 3 minutes
- Question 4: 3 minutes
- Question 5: 3 minutes
Patient Record Summary
Patient Details
- Name: John Mitchell
- Age: 72
- Gender: Male
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Nil known allergies
Medications
- Perindopril 5 mg daily (for hypertension)
Past History
- Hypertension (diagnosed 5 years ago, well-controlled).
- No prior cardiac events or procedures.
- No history of diabetes or significant renal disease.
Social History
- Retired accountant, lives with wife.
- Occasional alcohol use (1-2 glasses of wine per week).
- No smoking history, no illicit drug use.
- Generally active but has reduced exercise due to fatigue and palpitations.
Family History
- Father had a stroke at 75 years old.
- Mother had hypertension but no known cardiac disease.
Vaccination and Preventive Activities
- Influenza vaccine: Up to date
- COVID-19 booster: Received
- Routine blood tests last year: normal lipid profile and kidney function
Scenario
John Mitchell, a 72-year-old retired accountant, presents with palpitations and fatigue for the past 3 months.
He describes occasional shortness of breath on exertion but no chest pain or syncope.
He has a history of hypertension (on perindopril) and a family history of stroke.
He is worried about whether he has a heart condition and wants to know about treatment options.
On examination:
- BP: 138/86 mmHg
- HR: Irregularly irregular, 96 bpm
- Heart sounds: No murmurs, normal S1/S2
- Lungs: Clear
- No peripheral oedema
ECG Findings:
- Irregularly irregular rhythm, absent P waves, fibrillatory baseline – consistent with atrial fibrillation.
Likely Diagnosis:
Newly diagnosed atrial fibrillation (likely persistent).
Examiner Only Information
Questions
Q1. How would you explain John’s diagnosis and its implications?
- Prompt: How do you explain atrial fibrillation (AF) in simple terms?
- Prompt: What are the risks associated with AF, including stroke risk?
Q2. What further investigations are needed to assess John’s condition?
- Prompt: What baseline tests should be ordered?
- Prompt: How would you assess stroke risk?
Q3. What are the key components of John’s management plan?
- Prompt: Would you choose rate or rhythm control?
- Prompt: When would anticoagulation be indicated?
Q4. How would you educate John on lifestyle modifications and risk reduction?
- Prompt: What modifiable factors contribute to AF progression?
- Prompt: What lifestyle advice would you provide?
Q5. When would you consider referral to a cardiologist?
- Prompt: When is specialist input needed for rhythm control or catheter ablation?
- Prompt: When is urgent referral required?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you explain John’s diagnosis and its implications?
The competent candidate should:
- Explain atrial fibrillation (AF) in simple terms:
- “AF is a condition where the heart beats irregularly and sometimes faster than normal due to abnormal electrical activity.”
- “It can lead to symptoms like palpitations, fatigue, and breathlessness, and increases the risk of stroke.”
- Stroke risk:
- Blood can pool in the heart, forming clots that may travel to the brain and cause a stroke.
- The risk is assessed using the CHA₂DS₂-VASc score.
- Reassurance and treatment options:
- “AF is common and manageable with medications and lifestyle changes.”
- “We will assess whether you need medication to slow the heart rate, restore normal rhythm, or reduce stroke risk.”
Q2: What further investigations are needed to assess John’s condition?
The competent candidate should:
- Baseline cardiovascular and metabolic tests:
- ECG (to confirm AF and assess for rate, QRS, QT abnormalities).
- Echocardiogram (to check for structural heart disease or thrombus).
- 24-hour Holter monitor (if paroxysmal AF is suspected).
- Thyroid function tests (TSH, T4) (to exclude hyperthyroidism).
- FBC, U&E, LFTs (to check for anaemia, electrolyte imbalances, and liver function).
- Stroke risk assessment:
- CHA₂DS₂-VASc score to determine anticoagulation need.
- Bleeding risk assessment:
- HAS-BLED score to evaluate anticoagulation safety.
Q3: What are the key components of John’s management plan?
The competent candidate should:
- Rate vs rhythm control:
- Rate control preferred (e.g., beta-blockers or calcium channel blockers) unless symptomatic despite rate control.
- Rhythm control (cardioversion or antiarrhythmics) considered if AF is new onset (<48 hours) or significantly impacting quality of life.
- Anticoagulation for stroke prevention (based on CHA₂DS₂-VASc score):
- Warfarin or NOACs (e.g., apixaban, rivaroxaban) if high stroke risk.
- Discuss risks/benefits of anticoagulation based on HAS-BLED score.
- Blood pressure control:
- Ensure BP is well controlled to reduce AF progression and stroke risk.
Q4: How would you educate John on lifestyle modifications and risk reduction?
The competent candidate should:
- Lifestyle modifications to reduce AF triggers:
- Regular physical activity (moderate-intensity, avoiding excessive exertion).
- Limit caffeine and alcohol intake (excess alcohol can trigger AF).
- Maintain a healthy weight (obesity is a key AF risk factor).
- Manage stress and sleep disorders (e.g., screen for sleep apnoea).
- Regular monitoring and follow-up:
- Annual cardiovascular risk review.
- Blood tests every 6-12 months if on anticoagulation.
Q5: When would you consider referral to a cardiologist?
The competent candidate should:
- Urgent referral if:
- Severe symptoms (syncope, unstable BP, severe breathlessness).
- Uncontrolled heart rate despite medication (>110 bpm).
- Routine cardiology referral if:
- Rhythm control (e.g., electrical or pharmacological cardioversion) is being considered.
- High stroke risk requiring left atrial appendage closure (if anticoagulation contraindicated).
SUMMARY OF A COMPETENT ANSWER
- Explains AF in a patient-friendly way, addressing stroke risk and symptoms.
- Orders appropriate investigations, including ECG, echocardiogram, and CHA₂DS₂-VASc scoring.
- Develops a structured management plan, including rate control, anticoagulation, and lifestyle changes.
- Provides clear guidance on monitoring, follow-up, and when to seek urgent care.
- Recognises when referral to a cardiologist is required.
PITFALLS
- Failing to assess stroke risk with CHA₂DS₂-VASc score.
- Not discussing anticoagulation or misjudging bleeding risk.
- Overlooking modifiable risk factors such as weight, alcohol, or sleep apnoea.
- Not considering referral when symptoms are severe or persistent.
REFERENCES
- RACGP Guidelines on Atrial Fibrillation Management
- National Heart Foundation on AF Management Guide
- ESC Guidelines on Atrial Fibrillation
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 Explains AF in a way that the patient understands.
2. Clinical Information Gathering and Interpretation
2.1 Identifies symptoms, risk factors, and performs appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning
3.1 Uses CHA₂DS₂-VASc and HAS-BLED scores to guide anticoagulation decisions.
4. Clinical Management and Therapeutic Reasoning
4.1 Develops a management plan including rate control, anticoagulation, and lifestyle modification.
5. Preventive and Population Health
5.2 Encourages modifiable risk factor management.
6. Professionalism
6.3 Provides patient-centred, ethical care.
7. General Practice Systems and Regulatory Requirements
7.2 Ensures proper documentation and adherence to AF guidelines.
9. Managing Uncertainty
9.1 Recognises when rhythm control, referral, or urgent intervention is needed.
10. Identifying and Managing the Patient with Significant Illness
10.3 Identifies complications such as heart failure or high stroke risk.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD