CCE-CBD-171

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key components of the diagnosis and how do you explain this to the patient?

• Prompt: Confirm dilated cardiomyopathy as the diagnosis.
• Prompt: Discuss the role of hypertension and past alcohol use.
• Prompt: Address patient understanding and concerns about the condition.

Q2. What are the main management priorities for Michael in the general practice setting?

• Prompt: Discuss pharmacological management (ACE-I/ARB, beta-blocker, diuretics, etc.).
• Prompt: Consider device therapy and referral pathways.
• Prompt: Address lifestyle interventions and self-monitoring.

Q3. How would you manage Michael’s concerns about continuing work on the farm?

• Prompt: Explore strategies to manage fatigue and workload adjustments.
• Prompt: Consider support services (e.g., My Aged Care, NDIS if appropriate).
• Prompt: Review driving capacity and legal obligations.

Q4. What are the potential complications of this condition and how would you monitor and address them?

• Prompt: Discuss arrhythmias, thromboembolism, progression to severe heart failure.
• Prompt: Monitoring: BNP, echocardiography, renal function, electrolytes.
• Prompt: Plan for advance care discussions if appropriate.

Q5. How would you ensure culturally safe care and address the challenges of rural health delivery for Michael?

• Prompt: Provide culturally sensitive education and support services.
• Prompt: Address travel and access issues to specialists.
• Prompt: Discuss telehealth and chronic disease management plans (CDMP).

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key components of the diagnosis and how do you explain this to the patient?

Answer:

Michael, you’ve been diagnosed with Dilated Cardiomyopathy (DCM), which means the main pumping chamber of your heart (the left ventricle) has become enlarged and weakened. As a result, it isn’t pumping blood as efficiently as it should. On your echocardiogram, we saw that your heart’s pumping capacity (called ejection fraction) is about 30%, whereas we normally expect it to be over 50%.

The cause can be multifactorial, but in your case, there are several important factors:

• Long-standing high blood pressure, which puts extra strain on the heart.
• Past excessive alcohol use, which is a known risk factor for DCM. The fact you stopped drinking is excellent, but damage to the heart muscle may have already occurred.
• Sometimes, there can be a family history, as your father had heart failure too.

I understand this diagnosis may be concerning, but the key point is that there are effective treatments to slow the disease progression, improve symptoms, and help you maintain your quality of life.

I want to reassure you that we’ll work together to manage this. Our goal is to control your symptoms, reduce the workload on your heart, and minimise complications like irregular heart rhythms or fluid buildup.

You will have ongoing care, involving medications, lifestyle changes, and possibly referrals to specialists. Living in a rural area, we will explore telehealth consultations with cardiologists and regular reviews here in the practice.

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Q2: What are the main management priorities for Michael in the general practice setting?

Answer:

Michael’s management is multi-faceted and needs to be holistic, evidence-based, and tailored to his rural setting.

Pharmacological Management:

• ACE Inhibitors (or ARBs like Irbesartan, which he is already on) to reduce afterload and slow disease progression.
• Beta-blockers (e.g., Bisoprolol, Carvedilol): Essential for improving survival and reducing hospitalisations.
• Mineralocorticoid Receptor Antagonists (e.g., Spironolactone) to further reduce mortality.
• Diuretics (e.g., Frusemide): Symptomatic relief for fluid overload.
• Close monitoring of electrolytes and renal function is necessary due to these medications.

Lifestyle Interventions:

• Fluid and salt restriction to manage fluid overload.
• Weight monitoring daily to detect early fluid retention.
• Cardiac rehabilitation, even via telehealth, for supervised exercise and education.

Referral and Advanced Therapy:

• Referral to a cardiologist, possibly via telehealth, to assess for ICD (Implantable Cardioverter Defibrillator) if indicated by the ejection fraction and arrhythmia risk.
• Consideration for heart failure clinics if accessible.

Psychosocial Support:

• Addressing employment limitations and fatigue.
• Linking with My Aged Care or NDIS, as appropriate, for functional support.
• Mental health screening and support services, given the psychological burden.

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Q3: How would you manage Michael’s concerns about continuing work on the farm?

Answer:

Michael, it’s important we balance your health needs with your desire to remain active on the farm. Key strategies include:

• Modify workload: Prioritising lighter duties, avoiding heavy lifting, and scheduling tasks during cooler times to reduce strain.
• Pacing activities and incorporating regular rest breaks to manage fatigue.
• Monitoring for symptom exacerbation, especially shortness of breath or swelling.

We’ll arrange an Occupational Therapist review to assess workplace adjustments.

Given your role, we need to review driving eligibility according to Austroads guidelines, especially if you’re driving heavy machinery. We’ll document your fitness to drive or provide appropriate restrictions if needed.

It’s also worth discussing social supports—do you have family or workers who can assist? If not, My Aged Care can help connect you to domestic assistance services.

Importantly, we’ll ensure you’re involved in the decisions about your care and livelihood.

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Q4: What are the potential complications of this condition and how would you monitor and address them?

Answer:

Potential complications include:

• Arrhythmias (especially atrial fibrillation and ventricular tachycardia), increasing the risk of sudden cardiac death.
• Thromboembolic events (stroke, peripheral embolism), particularly if atrial fibrillation develops.
• Progressive heart failure leading to hospitalisation or end-stage heart failure.

Monitoring Plan:

• Regular clinical reviews every 4-6 weeks initially, focusing on symptoms, weight, BP, and fluid status.
• Ongoing blood tests (U&E, electrolytes, BNP) every 3 months.
• Repeat echocardiograms every 6-12 months.
• ECG monitoring for arrhythmias.
• Discuss advance care planning when appropriate.

Addressing complications:

• If arrhythmias are detected, consider ICD implantation.
• Anticoagulation may be needed if atrial fibrillation develops.
• Palliative care services if the condition becomes refractory.

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Q5: How would you ensure culturally safe care and address the challenges of rural health delivery for Michael?

Answer:

Although Michael is non-Indigenous, culturally safe care means respecting his rural background, values, and personal goals.

Rural Health Considerations:

• Maximise use of telehealth for cardiology consults and cardiac rehab programs.
• Provide chronic disease management plans (CDMP) to facilitate Medicare-funded allied health services.
• Coordinate with local community health services, including the rural outreach nurse.

Cultural Safety:

• Engage Michael in shared decision-making, ensuring his autonomy is respected.
• Use clear, jargon-free language to explain his condition and treatments.
• Respect his role as a farmer and the impact of the illness on his identity.

Address access barriers:

• Minimise travel by consolidating appointments.
• Ensure continuity of care with regular GP follow-ups and clear documentation.

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SUMMARY OF A COMPETENT ANSWER

• Clear explanation of the diagnosis of dilated cardiomyopathy tailored to Michael’s understanding.
• Evidence-based management addressing pharmacological and lifestyle interventions.
• Consideration of Michael’s occupation, addressing return-to-work issues sensitively.
• Monitoring for complications, with a comprehensive plan for potential arrhythmias and heart failure progression.
• Culturally safe care, addressing rural health barriers and integrating telehealth.

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PITFALLS

• Failing to address Michael’s concerns about his ability to work and quality of life.
• Overlooking telehealth opportunities and rural health resources.
• Inadequate monitoring of renal function and electrolytes on heart failure medications.
• Not recognising the importance of advanced care planning discussions.
• Neglecting psychosocial support and impact on mental health.

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REFERENCES

• National Heart Foundation of Australia on Guidelines for the prevention, detection and management of heart failure in Australia
• Austroads Guidelines on Assessing Fitness to Drive
• RACGP Guidelines on Management of Chronic 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 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 from history and examination.
2.2 Orders or selects appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Systematically and efficiently tests diagnostic hypotheses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.
4.2 Provides appropriate patient education and counselling.

5. Preventive and Population Health

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

6. Professionalism

6.1 Demonstrates respect, compassion, empathy and caring in patient 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 and explains it to patients.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and appropriately manages patients with potentially serious illnesses.

12. Rural Health Context (RH)

RH1.1 Considers rural context and resource limitations in patient care decisions.

Competency at Fellowship Level

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