CCE-CBD-141

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the possible causes of Margaret’s symptoms, and what is the most likely diagnosis?

• Prompt: Discuss differentials including medication side effects, autonomic dysfunction, and dehydration.
• Prompt: Identify postural hypotension as the likely cause and explain why.

Q2. How would you assess and confirm the diagnosis of postural hypotension?

• Prompt: Discuss clinical assessment, postural blood pressure measurement, and other investigations.

Q3. What would be your immediate management plan?

• Prompt: Discuss non-pharmacological and pharmacological options, medication review, and safety considerations.

Q4. What preventive strategies would you recommend to reduce her fall risk?

• Prompt: Discuss fall prevention, home safety, physiotherapy, and care coordination in a rural context.

Q5. How would you address Margaret’s concerns about independence and driving safety?

• Prompt: Discuss patient-centred communication, shared decision-making, and legal responsibilities regarding fitness to drive.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the possible causes of Margaret’s symptoms, and what is the most likely diagnosis?

Answer:

The patient’s main complaint is dizziness and lightheadedness upon standing, suggestive of orthostatic hypotension. A thorough differential diagnosis considers the following:

Differential Diagnoses:

• Postural (orthostatic) hypotension: Supported by significant BP drop upon standing.
• Medication-induced hypotension: Beta-blockers (Metoprolol) and ACE inhibitors (Perindopril) can contribute.
• Autonomic dysfunction: Common in diabetics due to autonomic neuropathy.
• Dehydration or volume depletion: Though no recent illness is reported, polyuria from poorly controlled diabetes (HbA1c 7.5%) may lead to relative hypovolaemia.
• Cardiac arrhythmias: Less likely due to normal HR and rhythm; still warrants consideration.
• Cerebrovascular insufficiency (vertebrobasilar insufficiency): Less likely, no neurological signs reported.

Most Likely Diagnosis:

• Postural (orthostatic) hypotension, based on:
  • Drop in systolic BP ≥20 mmHg and/or diastolic BP ≥10 mmHg within 3 minutes of standing (supine 135/80 to standing 100/60 mmHg).
  • Symptoms correlate with BP changes.
  • Risk factors: Age, diabetes, polypharmacy (multiple antihypertensives).

Relevant Australian guidelines such as RACGP’s Guidelines for Preventive Activities in General Practice (Red Book) and Therapeutic Guidelines: Cardiovascular recommend evaluating medication burden and hydration in older adults with postural hypotension.

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Q2: How would you assess and confirm the diagnosis of postural hypotension?

Answer:

History:

• Explore symptom pattern (onset, duration, positional relation).
• Ask about fluid intake, recent illness, heat exposure.
• Review medications for agents causing hypotension.

Examination:

• Postural BP measurement:
  • After 5 mins supine, measure BP and HR.
  • Stand patient up, measure BP and HR at 1 min and 3 mins.
  • Diagnostic if systolic BP drops ≥20 mmHg or diastolic BP drops ≥10 mmHg.
• Neurological exam: Rule out Parkinson’s disease, peripheral neuropathy.
• Cardiovascular exam: Check for murmurs, rhythm abnormalities.

Investigations:

• EUCs: Check for hyponatraemia, renal impairment (both noted in Margaret).
• HbA1c: Already elevated, indicating suboptimal glycaemic control.
• ECG: Rule out arrhythmias (no findings here but recommended).
• Tilt-table testing: Not commonly available in rural general practice; refer if uncertain.

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Q3: What would be your immediate management plan?

Answer:

Non-pharmacological Interventions:

• Educate Margaret on postural manoeuvres: rise slowly, sit before standing.
• Encourage hydration: at least 2L fluids daily unless contraindicated.
• Increase salt intake, cautiously, in consultation with a dietitian.
• Compression stockings (graded) to reduce venous pooling.

Medication Review:

• Consider withholding or reducing Metoprolol and/or Perindopril, balancing hypertension and fall risk.
• Monitor BP after changes.

Pharmacological Options:

• If symptoms persist, Fludrocortisone or Midodrine could be considered after specialist input, not first-line in general practice.

Safety Measures:

• Falls prevention strategies: home safety assessment, minimise tripping hazards.
• Physiotherapy: strength and balance training.
• Alert family/support services given her rural isolation.

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Q4: What preventive strategies would you recommend to reduce her fall risk?

Answer:

• Home environment modifications: Remove loose rugs, install grab rails.
• Vision assessment: Ensure cataract surgery outcomes are stable, updated glasses.
• Footwear: Encourage non-slip, well-fitting shoes.
• Exercise program: Refer to community-based falls prevention programs (e.g., Stepping On in NSW).
• Medication review: Deprescribing where appropriate.
• Monitoring: Arrange regular follow-up for BP monitoring and symptom review.
• Personal alarm system: Encourage a medical alert device in case of falls.
• Community services: Referral to My Aged Care for services such as Meals on Wheels, home help.

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Q5: How would you address Margaret’s concerns about independence and driving safety?

Answer:

Communication:

• Acknowledge her fears of losing independence.
• Emphasise collaborative planning to maintain autonomy and safety.

Driving Assessment:

• Discuss Austroads guidelines: drivers with conditions causing syncopal episodes must be assessed.
• Recommend a formal driving assessment through a fitness-to-drive evaluation.
• Suggest alternative transport options in the interim.

Supportive Measures:

• Encourage family involvement; liaise with her daughter.
• Discuss Advance Care Planning as part of proactive health management.
• Ensure Margaret feels involved in decisions, respecting her values and goals.

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SUMMARY OF A COMPETENT ANSWER

• Identifies postural hypotension as the most likely cause of Margaret’s symptoms.
• Demonstrates comprehensive history taking and clinical assessment, including postural BP measurement.
• Implements a patient-centred management plan, prioritising safety and fall prevention.
• Reviews medications thoughtfully, balancing comorbidities and polypharmacy risks.
• Addresses psychosocial concerns, maintaining patient autonomy and dignity.
• Refers appropriately for specialist input or community services.

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PITFALLS

• Failure to recognise medication-induced hypotension, particularly with beta-blockers and ACE inhibitors.
• Overlooking fall risk and neglecting a comprehensive falls prevention plan.
• Not involving the patient in decision-making, compromising autonomy.
• Neglecting rural health context, such as access to services and family support limitations.
• Inadequate discussion of driving safety and legal responsibilities.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• National Institutes of Health on Cardiovascular (Postural Hypotension)
• Austroads Fitness to Drive Guidelines

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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, 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 information about health needs, including the patient’s life stage and context.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health needs.
3.2 Demonstrates diagnostic reasoning and clinical judgment.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements patient-centred management plans.
4.2 Applies evidence-based medicine and shared decision-making.

5. Preventive and Population Health

5.1 Provides health promotion and disease prevention strategies.

6. Professionalism

6.1 Adheres to ethical, legal, and professional standards.

7. General Practice Systems and Regulatory Requirements

7.1 Practices within the Australian health care system and understands referral pathways.

9. Managing Uncertainty

9.1 Manages uncertainty and risk in decision-making.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and responds to potentially life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates knowledge and understanding of rural health context and resource availability.

Competency at Fellowship Level

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