CCE-CBD-194

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between vasovagal, cardiac, and neurological causes of syncope?
• Prompt: What features would raise suspicion for a serious underlying condition?

Q2. What are your initial management steps?

• Prompt: What investigations are required at this stage?
• Prompt: When would you refer for specialist review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you reassure her regarding the benign nature of vasovagal syncope?
• Prompt: What lifestyle modifications would you recommend?

Q4. What preventive measures can help reduce her risk of recurrence?

• Prompt: What advice can she implement to avoid future episodes?
• Prompt: When should she seek further medical attention?

Q5. What are the red flags that would necessitate urgent referral or emergency intervention?

• Prompt: What clinical features suggest a high-risk cardiac or neurological cause of syncope?
• Prompt: How would you manage a patient presenting with exertional or recurrent syncope?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Syncope is transient loss of consciousness due to cerebral hypoperfusion, with several possible causes.

Differential Diagnoses:

1. Vasovagal Syncope (Most Likely Diagnosis)
   • Key features: Preceding lightheadedness, nausea, standing for prolonged periods, rapid recovery.
   • Common in younger individuals, often triggered by stress, heat, or dehydration.
2. Orthostatic Hypotension
   • Key features: BP drop on standing, volume depletion, medication-related (e.g., antihypertensives).
   • Confirmed by a postural drop in BP.
3. Cardiac Arrhythmias (Red Flag Cause)
   • Key features: Sudden syncope without prodrome, history of palpitations.
   • Needs urgent ECG, Holter monitor.
4. Structural Heart Disease (e.g., Aortic Stenosis, Hypertrophic Cardiomyopathy)
   • Key features: Exertional syncope, chest pain, murmur.
   • Requires echocardiogram for diagnosis.
5. Neurological Causes (Less Likely Here)
   • Seizures – Post-ictal confusion, tongue biting, aura.
   • TIA/Stroke – Persistent neurological deficits.

Most Likely Diagnosis:

• Vasovagal syncope, given clear triggers (heat, standing), prodrome, and rapid recovery.
• Confirmed with history and postural BP assessment.

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Q2: What are your initial management steps?

Answer:

1. Confirm Diagnosis and Assess Risk

• Postural BP measurement (rule out orthostatic hypotension).
• ECG (rule out arrhythmia or cardiac causes).
• FBC, UECs, glucose (exclude anaemia, electrolyte abnormalities).

2. Acute Management

• Reassure patient that vasovagal syncope is usually benign.
• Encourage hydration, electrolyte balance.

3. Specialist Referral Criteria

• Cardiology referral if:
  • Abnormal ECG, recurrent episodes, exertional syncope.
• Neurology referral if suspected seizure or focal neurological symptoms.

4. Follow-Up Plan

• Review in 4 weeks to reassess symptoms.
• Advise immediate return if syncope recurs or worsens.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your fainting episode is most likely due to vasovagal syncope, a common condition where your blood pressure temporarily drops, reducing blood flow to the brain.”
• “This can happen when standing for long periods, heat exposure, or dehydration.”

Treatment Plan:

• “We will perform some tests, including blood pressure checks, an ECG, and blood tests to rule out other causes.”
• “You should stay well-hydrated, avoid prolonged standing, and recognise early symptoms to prevent recurrence.”

Safety-Netting:

• “If you experience chest pain, prolonged loss of consciousness, or recurrent fainting, seek urgent care.”
• “We will review you in 4 weeks to monitor progress.”

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Q4: What preventive measures can help reduce her risk of recurrence?

Answer:

• Lifestyle Modifications:
  • Increase fluid and salt intake to improve BP control.
  • Avoid standing for long periods, especially in warm environments.
• Physical Counterpressure Manoeuvres:
  • Crossing legs, clenching fists to maintain blood pressure when symptoms arise.
• Medical Review:
  • Adjust medications if contributing to low BP.
  • Consider compression stockings if recurrent.
• Monitoring & Follow-Up:
  • Review in 4 weeks, earlier if symptoms persist.
  • Educate on red flags requiring urgent medical review.

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Q5: What are the red flags that would necessitate urgent referral or emergency intervention?

Answer:

• Exertional syncope (suggesting structural heart disease).
• Syncope with chest pain, palpitations, or breathlessness.
• Abnormal ECG (QT prolongation, AV block, arrhythmias).
• Family history of sudden cardiac death.
• Persistent neurological symptoms (suggesting TIA/stroke).

Emergency Management of High-Risk Syncope:

• Call 000 for urgent transfer.
• Immediate ECG, BP monitoring.
• IV fluids if dehydration suspected.
• Cardiology admission if high-risk features present.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates between vasovagal, cardiac, and neurological causes.
• Recognises vasovagal syncope as the most likely diagnosis.
• Orders appropriate investigations (ECG, blood tests, postural BP).
• Provides lifestyle and medical management.
• Recognises red flags requiring urgent referral.

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PITFALLS

• Failing to consider cardiac arrhythmias or structural heart disease.
• Not assessing postural BP to rule out orthostatic hypotension.
• Reassuring without ordering an ECG to exclude cardiac causes.
• Delaying referral for exertional syncope or abnormal ECG findings.

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REFERENCES

• 
  RACGP Guidelines – Cardiovascular Risk Assessment
• GP Exams – Fainting/syncope

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to syncope.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign and life-threatening causes of syncope.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including lifestyle modifications.
4.2 Recognises when urgent investigations or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on avoiding triggers and minimising risk of recurrence.

Competency at Fellowship Level

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