EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Alan’s symptoms?

• Prompt: How does his past medical history influence your differentials?
• Prompt: What red flag conditions need exclusion?

Q2. What further history would you elicit to confirm the diagnosis?

• Prompt: What risk factors for worsening heart failure should you explore?
• Prompt: How does his lifestyle and medication adherence affect management?

Q3. What investigations would you order and why?

• Prompt: What bedside, laboratory, and imaging tests would you request?
• Prompt: When would you consider an echocardiogram?

Q4. Outline your management plan for Alan’s heart failure.

• Prompt: What pharmacological and non-pharmacological treatments are indicated?
• Prompt: How would you manage fluid overload and lifestyle modifications?

Q5. What are the follow-up and safety-netting considerations?

• Prompt: When should he be referred to a specialist?
• Prompt: What complications should he monitor for?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are your differential diagnoses for Alan’s symptoms?

A competent candidate should provide a structured approach to differential diagnoses, considering:

• Heart failure (most likely): Progressive dyspnoea, orthopnoea, ankle oedema, raised JVP, displaced apex beat, S3 heart sound, and basal crackles are highly suggestive.
• Chronic obstructive pulmonary disease (COPD): Given the history of smoking, exertional dyspnoea could be due to COPD rather than cardiac failure. However, lack of wheeze and productive cough makes this less likely.
• Ischaemic heart disease (IHD): Past MI suggests possible ongoing ischaemia or worsening cardiac function.
• Chronic kidney disease (CKD): Fluid retention can be due to reduced renal function, especially if nephrotic syndrome or CKD is present.
• Liver disease: Chronic hepatic congestion (e.g., secondary to right heart failure) could contribute to peripheral oedema.
• Venous insufficiency: Lower limb oedema can occur without systemic involvement but would not typically cause breathlessness.

Red flags to exclude include worsening heart failure (pulmonary oedema), acute coronary syndrome, or pulmonary embolism.

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Q2: What further history would you elicit to confirm the diagnosis?

• Cardiac symptoms: Severity and progression of dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, chest pain, palpitations.
• Fluid retention history: Onset, diurnal variation, worsening leg swelling, weight gain.
• Medication adherence: Irregular perindopril use may contribute to worsening heart failure.
• Risk factors: History of hypertension, diabetes, hyperlipidaemia, past MI.
• Exercise tolerance: Any decline in functional capacity (New York Heart Association classification).
• Lifestyle factors: Salt intake, alcohol, smoking history.
• Family history: History of heart failure or cardiomyopathy.

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Q3: What investigations would you order and why?

• Bedside tests:
  • ECG (ischaemic changes, arrhythmia, left ventricular hypertrophy).
  • BNP/NT-proBNP (elevated in heart failure).
• Laboratory tests:
  • Full blood count (anaemia may exacerbate heart failure).
  • UECs (renal impairment due to cardiorenal syndrome).
  • Liver function tests (hepatic congestion).
  • Fasting glucose/HbA1c and lipid profile (cardiovascular risk assessment).
• Imaging:
  • Chest X-ray (pulmonary congestion, cardiomegaly, pleural effusions).
  • Echocardiogram (gold standard for assessing left ventricular function and ejection fraction).

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Q4: Outline your management plan for Alan’s heart failure.

• Non-pharmacological management:
  • Dietary advice: Fluid restriction (<1.5L/day), salt restriction.
  • Daily weight monitoring: >2 kg weight gain in 2 days suggests fluid overload.
  • Exercise and rehabilitation: Referral for cardiac rehabilitation if appropriate.
• Pharmacological management:
  • Diuretics (e.g., furosemide) for symptom relief (reduce congestion).
  • ACE inhibitors (e.g., perindopril) to reduce afterload and prevent progression (ensure adherence).
  • Beta-blockers (e.g., bisoprolol) to improve survival and reduce hospitalisation risk.
  • Aldosterone antagonists (e.g., spironolactone) if ejection fraction is reduced.
  • Consider SGLT2 inhibitors (dapagliflozin) if diabetic or if recommended in HFrEF.
• Referral to cardiology if symptoms persist or significant left ventricular dysfunction is found.

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Q5: What are the follow-up and safety-netting considerations?

• Regular GP review (2–4 weeks initially) to assess response to treatment, monitor weight, and optimise medications.
• Monitor for signs of worsening heart failure: Increased dyspnoea, orthopnoea, rapid weight gain (>2 kg in 2 days).
• Titrate medications gradually (start low, go slow).
• Ensure vaccination status is up to date (influenza, pneumococcal, COVID-19).
• Referral to heart failure clinic or cardiologist if symptoms are severe or refractory.

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SUMMARY OF A COMPETENT ANSWER

• Identifies heart failure as the most likely diagnosis while considering important differentials.
• Recognises red flags requiring urgent referral or hospitalisation.
• Orders appropriate investigations, including BNP, echocardiogram, and CXR.
• Provides an evidence-based management plan, including pharmacological, non-pharmacological, and lifestyle interventions.
• Implements safety-netting strategies with structured follow-up and escalation plans.

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PITFALLS

• Failing to consider differentials such as CKD, liver disease, or venous insufficiency.
• Not ordering BNP or echocardiography, missing heart failure diagnosis.
• Prescribing diuretics alone without optimising heart failure medications (ACE inhibitors, beta-blockers).
• Neglecting fluid and salt restriction advice, which is crucial for symptom control.
• Lack of follow-up planning, missing an opportunity for titration of medications and early intervention.

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REFERENCES

• RACGP – RACGP Guidelines for Heart Failure Management
• GP Exams – Heart Failure

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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 Establishes rapport and gathers information about symptoms and impact on daily life.
1.2 Explains the diagnosis and management plan in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including cardiac risk factors and medication adherence.
2.2 Performs a targeted examination to assess heart failure severity.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies heart failure as the most likely diagnosis while considering differentials.
3.2 Recognises red flags indicating decompensated heart failure.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions.
4.2 Implements symptom control strategies and referral pathways if required.

5. Preventive and Population Health

5.1 Provides lifestyle education, including diet, fluid restriction, and weight monitoring.

6. Professionalism

6.1 Demonstrates empathy and patient-centred care, addressing concerns about prognosis and quality of life.

7. General Practice Systems and Regulatory Requirements

7.1 Documents clinical findings, management plans, and follow-up clearly.

8. Procedural Skills

8.1 Demonstrates correct technique in performing and interpreting cardiovascular examination.

9. Managing Uncertainty

9.1 Plans appropriate follow-up and escalation if symptoms worsen.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises signs of worsening heart failure requiring urgent intervention.

Competency at Fellowship Level

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