CCE-CBD-193

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between benign and pathological arrhythmias?
• Prompt: What features would raise suspicion for a serious underlying condition?

Q2. What are your initial management steps?

• Prompt: What investigations are required at this stage?
• Prompt: When would you refer for cardiology review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address his concerns about a heart condition?
• Prompt: What lifestyle modifications and pharmacological treatments would you recommend?

Q4. What preventive measures can help reduce his risk of cardiovascular disease and arrhythmias?

• Prompt: What lifestyle changes should he adopt?
• Prompt: What long-term monitoring is needed?

Q5. What are the red flags that would necessitate urgent referral or emergency intervention?

• Prompt: What clinical features suggest a life-threatening arrhythmia?
• Prompt: How would you manage a patient presenting with haemodynamically unstable arrhythmia?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Palpitations and intermittent tachycardia can arise from benign, cardiac, metabolic, and psychological causes. Identifying concerning features is essential.

Differential Diagnoses:

1. Supraventricular Tachycardia (SVT) – Most Likely Diagnosis
   • Key features: Sudden onset, brief episodes of rapid heartbeat, dizziness.
   • Often triggered by stress, caffeine, or alcohol.
2. Atrial Fibrillation (Paroxysmal AF)
   • Key features: Irregular, rapid palpitations, occasional dizziness.
   • Risk factors: Hypertension, sedentary lifestyle, alcohol.
3. Ventricular Arrhythmias
   • Key features: More dangerous, associated with syncope, severe dizziness.
   • Usually occurs in those with structural heart disease.
4. Non-cardiac Causes
   • Hyperthyroidism – Heat intolerance, tremors, weight loss.
   • Electrolyte imbalance (hypokalaemia, hypomagnesaemia).
   • Anxiety-related palpitations – Associated with stress, hyperventilation.

Most Likely Diagnosis:

• SVT or paroxysmal AF based on intermittent episodes of tachycardia and dizziness.
• Requires Holter monitoring to confirm arrhythmia type.

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Q2: What are your initial management steps?

Answer:

1. Investigations to Identify Arrhythmia and Underlying Causes

• ECG (at rest): Normal, but may miss intermittent arrhythmias.
• Holter Monitor (24–48 hrs): Confirms paroxysmal arrhythmias.
• Blood tests:
  • FBC (anaemia), UECs (electrolytes), TSH (thyroid function).

2. Acute and Preventive Management

• If palpitations occur in consultation:
  • Vagal manoeuvres (Valsalva, carotid massage if no contraindications).
  • ECG during an episode (if feasible).
• Lifestyle modifications:
  • Reduce caffeine, alcohol, and stress.
  • Improve fitness, weight loss to reduce cardiovascular risk.
• Medications (if persistent symptoms):
  • Beta-blockers or calcium channel blockers (rate control).

3. Referral Criteria for Specialist Review

• Cardiology referral if:
  • Arrhythmia confirmed (SVT or AF).
  • Symptoms persist despite lifestyle modifications.

4. Follow-Up Plan

• Review in 2-4 weeks with Holter results.
• Safety-net for worsening symptoms (syncope, chest pain, breathlessness).

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms suggest a heart rhythm disturbance called supraventricular tachycardia (SVT) or atrial fibrillation (AF).”
• “This means that your heart occasionally beats too fast due to an electrical issue.”

Treatment Plan:

• “We will use Holter monitoring to confirm the diagnosis and blood tests to rule out contributing factors.”
• “In the meantime, you can try lifestyle changes (reduce stress, caffeine, alcohol) and techniques like deep breathing or Valsalva manoeuvre when an episode occurs.”
• “If symptoms persist, we may consider medication or referral to a cardiologist.”

Safety-Netting:

• “If you develop chest pain, severe dizziness, or fainting, seek urgent medical care (000).“
• “We will follow up in 2-4 weeks to discuss your test results.”

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Q4: What preventive measures can help reduce his risk of cardiovascular disease and arrhythmias?

Answer:

• Lifestyle modifications:
  • Reduce caffeine, alcohol, high-sugar intake.
  • Regular exercise and weight control.
  • Smoking cessation (if applicable).
• Stress management:
  • Yoga, meditation, and relaxation techniques to reduce triggers.
• Monitor and manage cardiovascular risk factors:
  • Hypertension control (review need for medication adjustment).
  • Regular lipid and glucose screening (assess metabolic risk).
• Regular follow-up for arrhythmia surveillance.

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Q5: What are the red flags that would necessitate urgent referral or emergency intervention?

Answer:

• Syncope (fainting) or near-syncope.
• Chest pain, shortness of breath, or signs of heart failure.
• Sustained tachycardia (>180 bpm) lasting >30 minutes.
• Hypotension, confusion, or shock.

Emergency Management of Haemodynamically Unstable Arrhythmia:

• Call 000 for urgent transfer to hospital.
• ECG and IV access.
• If haemodynamically unstable AF/SVT → urgent cardioversion in ED.
• Start IV beta-blockers or amiodarone if required in hospital.

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SUMMARY OF A COMPETENT ANSWER

• Correctly differentiates between benign and pathological arrhythmias.
• Recognises paroxysmal SVT or AF as the likely cause.
• Orders appropriate investigations (ECG, Holter, blood tests).
• Provides lifestyle advice and pharmacological options if needed.
• Recognises red flags requiring emergency intervention.

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PITFALLS

• Failing to consider cardiac arrhythmias in intermittent palpitations.
• Not ordering a Holter monitor to capture episodic arrhythmia.
• Overlooking lifestyle and cardiovascular risk factors.
• Missing red flags requiring urgent cardiology referral.

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REFERENCES

• 
  RACGP Guidelines – Cardiovascular Disease
• GP Exams – Cardiac arrhythmia NOS

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to palpitations and arrhythmias.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign and pathological arrhythmias.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including lifestyle and pharmacological interventions.
4.2 Recognises when urgent investigations or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on lifestyle modifications and risk reduction strategies.

Competency at Fellowship Level

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