CCE-CBD-167

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis for Michael’s palpitations?

• Consider both cardiac and non-cardiac causes
• Justify your leading diagnosis (Atrial Fibrillation)

Q2. What investigations would you order and why?

• Immediate tests: ECG, electrolytes, thyroid function
• Further tests: Holter monitoring, echocardiogram, stress testing

Q3. How would you manage Michael’s atrial fibrillation both acutely and in the long term?

• Acute rate control: Beta-blockers / calcium channel blockers
• Stroke prevention: CHA₂DS₂-VASc score to guide anticoagulation
• Discuss rhythm control options
• Lifestyle modification: Reduce caffeine, manage stress, increase physical activity

Q4. How would you counsel Michael on lifestyle changes and prevention of complications?

• Smoking/alcohol/caffeine advice
• Regular exercise
• Stress management strategies
• Importance of medication adherence and regular monitoring

Q5. How would you address uncertainty in this case, including follow-up planning?

• Organise follow-up in 1 week to review response to therapy and arrange specialist referral if necessary
• Explain red flags: worsening palpitations, syncope, chest pain
• Safety netting: When to seek urgent review

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis for Michael’s palpitations?

Answer:

For Michael Thompson, a 45-year-old male presenting with palpitations, the differential diagnosis includes both cardiac and non-cardiac causes.

Cardiac causes

• Atrial Fibrillation (AF): This is the leading diagnosis given the irregularly irregular pulse and ECG findings confirming AF with a ventricular response rate of 110 bpm. His risk factors include hypertension, sedentary lifestyle, and family history of cardiovascular disease.
• Atrial Flutter: Similar to AF but often with a regular rhythm; less likely due to irregular pulse.
• Supraventricular Tachycardia (SVT): Typically presents with sudden-onset rapid palpitations but is often regular in rhythm.
• Ventricular ectopics or tachycardia: Less likely, but should be considered in structurally abnormal hearts.

Non-cardiac causes

• Thyrotoxicosis: Ruled out based on normal TSH.
• Anxiety/Panic Disorder: Although stress is a contributor, Michael’s palpitations are consistent with AF.
• Stimulant use (Caffeine, alcohol): Contributory factors in AF; Michael reports increased caffeine use.
• Electrolyte imbalance: Ruled out with normal electrolytes.

In conclusion, Atrial Fibrillation is the most likely diagnosis, with contributing factors including hypertension, lifestyle, and stress. This diagnosis is confirmed by clinical signs and ECG findings.

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Q2: What investigations would you order and why?

Answer:

Following the confirmation of AF, the next step is to conduct further investigations to determine underlying causes, assess cardiac function, and evaluate stroke risk.

Immediate investigations already completed

• ECG: Shows AF with ventricular rate of 110 bpm.
• TSH and electrolytes: Normal.
• Renal function and haemoglobin: Normal.

Further investigations

1. Echocardiogram (Transthoracic Echo):
   • To assess for structural heart disease, left atrial size, left ventricular function, and presence of valvular disease, especially mitral stenosis.
2. Holter Monitor (24-48 hours):
   • To evaluate the frequency and duration of AF episodes, and to detect other arrhythmias if paroxysmal.
3. Fasting Lipids and HbA1c:
   • Assess cardiovascular risk factors as part of the long-term management of AF.
4. Sleep Study (Polysomnography):
   • If clinical suspicion of obstructive sleep apnoea, which is a risk factor for AF.
5. Chest X-Ray:
   • Optional. To assess heart size and pulmonary vasculature in certain cases.

The rationale for these investigations is to ensure that no underlying reversible cause or structural abnormality is missed and to stratify stroke risk.

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Q3: How would you manage Michael’s atrial fibrillation both acutely and in the long term?

Answer:

Acute management

• Rate control: First-line in stable AF. Options include:
  • Beta-blockers (Metoprolol): Preferred if no contraindications.
  • Calcium channel blockers (Diltiazem): Alternative if beta-blockers contraindicated.
• Rhythm control: Consider if recent onset (<48 hrs) or symptomatic despite rate control. Cardioversion may be appropriate post-transoesophageal echocardiogram or after 3 weeks of anticoagulation.
• Stroke prevention: Assess CHA₂DS₂-VASc score. Michael scores 1 (hypertension), so anticoagulation is advised following guideline discussions.
  • Direct Oral Anticoagulant (DOAC): E.g., Apixaban, preferred for stroke prevention unless contraindicated.

Long-term management

• Rate or Rhythm control strategy: Based on symptoms, underlying heart disease, and patient preference.
• Anticoagulation: Continued as long as stroke risk remains elevated.
• Lifestyle modifications:
  • Reduce caffeine and alcohol.
  • Regular physical activity to address hypertension and weight.
  • Stress management techniques.
• Manage cardiovascular risks: Control hypertension, consider statins if lipid profile elevated.
• Referral to cardiologist: For persistent AF, consideration of ablation if refractory to medication.
• Regular follow-up: Monitor for anticoagulation complications and control of AF.

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Q4: How would you counsel Michael on lifestyle changes and prevention of complications?

Answer:

Counselling should be patient-centred, considering Michael’s preferences and concerns.

Discussion points:

• Understanding AF: Explain that AF can increase stroke risk and why treatment adherence is crucial.
• Anticoagulation: Discuss risks/benefits of DOACs, including potential bleeding.
• Lifestyle modification:
  • Reduce caffeine and alcohol to lower AF triggers.
  • Weight loss if BMI >25, aiming for <25 kg/m².
  • Exercise: Recommend at least 150 mins/week of moderate activity.
  • Stress management: Mindfulness, relaxation techniques. Offer referral for psychological support if high stress.
• Smoking cessation (not applicable here but always worth revisiting).
• Monitoring: Explain need for regular reviews, blood tests, and possible escalation of care.
• Red flags: Advise when to seek urgent care (syncope, chest pain, severe breathlessness).

Educational resources such as Heart Foundation materials can support counselling.

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Q5: How would you address uncertainty in this case, including follow-up planning?

Answer:

Managing uncertainty involves clear communication, structured follow-up, and safety netting.

Communication:

• Acknowledge that AF can be unpredictable and reassure Michael of evidence-based management.
• Explain the rationale behind each treatment choice and potential outcomes.

Safety netting:

• Red flags to watch for: worsening palpitations, syncope, chest pain, stroke symptoms.
• Emergency contacts and when to attend ED.

Follow-up:

• Review in 1 week to evaluate rate control efficacy and check anticoagulation tolerance.
• Discuss ECHO results when available and further management.
• Ongoing review every 3 months or earlier as needed.

Specialist referral:

• If Michael has persistent symptoms despite optimal management or is a candidate for ablation.

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SUMMARY OF A COMPETENT ANSWER

• Demonstrates a systematic differential diagnosis, focusing on cardiac causes.
• Orders appropriate investigations to clarify diagnosis and rule out secondary causes.
• Provides a clear, evidence-based management plan for acute and chronic atrial fibrillation.
• Incorporates preventive health and lifestyle modification counselling effectively.
• Demonstrates safe practice with safety netting and clear follow-up planning.

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PITFALLS

• Failing to consider stroke prevention via anticoagulation in AF.
• Omitting to address lifestyle risk factors (e.g., caffeine, weight).
• Not explaining red flags or providing safety netting advice.
• Overlooking long-term follow-up or referral to a cardiologist if needed.
• Using medical jargon that is not understood by the patient.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Australian Therapeutic Guidelines on Cardiovascular (2023)
• NHFA/CSANZ Atrial Fibrillation Guidelines (2018)
• CHA₂DS₂-VASc Scoring

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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 findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Rationally selects and interprets relevant investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.
4.2 Provides appropriate emergency care.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses practice systems effectively and safely.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially life-threatening conditions.

Competency at Fellowship Level

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