CCE-CBD-146

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis for David’s ankle swelling?

• Prompt: Discuss both cardiac and non-cardiac causes
• Prompt: Justify your reasoning based on clinical findings

Q2. What further investigations or referrals would you organise at this point?

• Prompt: Justify each investigation in relation to your diagnosis
• Prompt: Consider access in a rural context

Q3. Outline your initial management plan for David.

• Prompt: Include both pharmacological and non-pharmacological strategies
• Prompt: Consider shared decision-making and rural health limitations

Q4. How would you communicate the possible diagnosis and management options to David?

• Prompt: Address his concerns about heart failure and rural access
• Prompt: Include safety-netting advice

Q5. What preventive and long-term management strategies would you implement?

• Prompt: Address chronic disease management in a rural setting
• Prompt: Focus on cardiovascular risk factors

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis for David’s ankle swelling?

A comprehensive differential diagnosis for bilateral lower limb oedema should consider systemic, cardiac, renal, hepatic, and venous causes. Given David’s presentation and history, the key differentials include:

1. Chronic Heart Failure (Right-sided or Biventricular)

• Supporting factors: Progressive bilateral ankle swelling, mild exertional dyspnoea, family history of heart failure, elevated BNP.
• However, normal JVP and clear lung fields reduce the likelihood of decompensated heart failure.

2. Chronic Venous Insufficiency

• Bilateral nature, worse at the end of the day, improves overnight.
• Common in older adults, particularly those with prolonged standing histories (e.g. farming).

3. Hypoalbuminaemia (Nephrotic syndrome or hepatic causes)

• Serum albumin is low (30 g/L).
• Urinalysis shows proteinuria (+1), suggesting some protein loss, although not in nephrotic range.
• No signs of liver disease on examination.

4. Renal Impairment

• eGFR 58 mL/min suggests chronic kidney disease (CKD) stage 3a.
• CKD can lead to sodium and fluid retention.

5. Medication-induced Oedema

• ACE inhibitors (Perindopril) can rarely contribute to oedema, although less common than calcium channel blockers.

Less likely causes (but should consider if the clinical picture changes):

• Deep Vein Thrombosis (bilateral is rare; no calf tenderness, no asymmetry).
• Hypothyroidism (no symptoms provided, but a TSH would clarify).
• Drugs (NSAIDs, steroids – not used here).

Q2: What further investigations or referrals would you organise at this point?

Investigations:

• Chest X-ray – Assess for cardiomegaly, pulmonary congestion.
• ECG – Look for signs of ischaemia, arrhythmias.
• Echocardiogram – Evaluate cardiac structure and function. Essential if heart failure suspected.
• Urinary ACR (Albumin-to-Creatinine Ratio) – Further quantify proteinuria.
• Liver Function Tests – Rule out hepatic causes of hypoalbuminaemia.
• TSH – Rule out hypothyroidism.
• Full Blood Count – Anaemia can worsen heart failure.

Referral:

• Cardiology – If echocardiogram reveals significant cardiac dysfunction.
• Nephrology – If proteinuria/renal impairment worsens.
• Consider telehealth consultations due to rural location.

Q3: Outline your initial management plan for David.

Pharmacological:

• Start Frusemide (20-40 mg daily) – Symptomatic relief of oedema, monitor renal function and electrolytes.
• Optimise ACE inhibitor (Perindopril) dose if tolerated, considering renal function.
• Consider statin therapy if cardiovascular risk assessment supports.
• Aspirin: Reassess need—currently self-initiated without clear indication.

Non-Pharmacological:

• Leg elevation and compression stockings (after ruling out arterial insufficiency).
• Salt restriction.
• Weight monitoring.
• Education on heart failure signs (if relevant) and when to seek urgent care.

Monitoring:

• Regular review of renal function and electrolytes, particularly after initiating diuretics.
• Blood pressure control and diabetes optimisation (review HbA1c).

Q4: How would you communicate the possible diagnosis and management options to David?

• Use simple, non-medical language.
• Explain findings suggest fluid retention, possibly related to mild heart strain or kidney function.
• Acknowledge his concerns about heart failure, but reassure him that further tests (e.g., echocardiogram) will clarify this.
• Discuss treatment options and their benefits/risks, including side effects of diuretics.
• Emphasise the importance of monitoring weight, leg swelling, and breathing.
• Discuss telehealth options to minimise travel and ensure continuity of care.
• Provide clear safety-netting advice, e.g., increased breathlessness, weight gain >2 kg in 2 days.

Q5: What preventive and long-term management strategies would you implement?

Chronic Disease Management:

• Diabetes control – Aim HbA1c <7% (individualised target).
• Hypertension management – Ongoing monitoring.
• CKD monitoring – Regular eGFR, electrolytes, urinary ACR.

Cardiovascular Risk Reduction:

• Absolute cardiovascular risk assessment – Supports decision on statins and antiplatelets.
• Lifestyle advice – Diet, physical activity suited to his capabilities.
• Smoking cessation reinforcement (already non-smoker).

Vaccinations:

• Continue annual influenza and pneumococcal vaccinations.

Care Coordination:

• Consider enrolment in Chronic Disease Management (CDM) plan.
• GP Management Plan and Team Care Arrangements for allied health involvement.

SUMMARY OF A COMPETENT ANSWER

• Thorough differential diagnosis including cardiac, renal, and venous causes.
• Appropriate investigations considering rural limitations.
• Clear management plan, including pharmacological and lifestyle strategies.
• Effective communication, addressing patient concerns and rural context.
• Focus on preventive health and chronic disease management.

PITFALLS

• Failure to consider non-cardiac causes such as renal or venous insufficiency.
• Overlooking rural health challenges, e.g., access to specialists.
• Not safety-netting effectively, especially regarding worsening symptoms.
• Inadequate medication review, particularly self-initiated aspirin use.
• Not considering compression therapy after ruling out arterial insufficiency.

REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (“Red Book”)
• Australian Heart Foundation Heart Failure Guidelines
• Kidney Health Australia CKD Management Handbook

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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.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses.
3.2 Demonstrates diagnostic reasoning and clinical judgement.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Provides appropriate advice and support.

5. Preventive and Population Health

5.1 Provides advice and interventions to promote wellbeing.

6. Professionalism

6.1 Adheres to ethical and professional standards.

7. General Practice Systems and Regulatory Requirements

7.1 Uses health information systems appropriately.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical decision-making.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages serious and life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Manages complex care within a rural and remote context.

Competency at Fellowship Level

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