CCE-CBD-224

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your provisional diagnosis and differential diagnoses?

• Prompt: What clinical features support your provisional diagnosis?
• Prompt: What alternative diagnoses should be considered?

Q2. What investigations are required to confirm the diagnosis?

• Prompt: What are the key investigations and their rationale?
• Prompt: What imaging modality is preferred in suspected IE?

Q3. Outline the immediate and long-term management of this patient.

• Prompt: What are the initial steps in management?
• Prompt: When would you refer this patient?
• Prompt: What is the long-term approach to preventing recurrence?

Q4. How would you communicate the diagnosis and management plan to the patient?

• Prompt: What key points must be discussed with the patient?
• Prompt: How would you ensure adherence to treatment?

Q5. What are the preventive strategies for infective endocarditis?

• Prompt: What patient education is required?
• Prompt: When is antibiotic prophylaxis indicated?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your provisional diagnosis and differential diagnoses?

The provisional diagnosis in this case is infective endocarditis (IE) based on:

• Persistent fever (38.5°C), night sweats, and weight loss.
• New murmur indicating possible valvular involvement.
• Peripheral stigmata of IE, including Janeway lesions and splinter haemorrhages.
• Positive blood cultures showing Staphylococcus aureus.
• Echocardiographic evidence of a vegetation on the mitral valve.

Differential Diagnoses

• Other causes of bacteraemia and sepsis: Given the positive blood cultures, alternative sources (e.g., osteomyelitis, pneumonia, pyelonephritis) should be considered.
• Non-infective endocarditis (e.g., Libman-Sacks endocarditis in lupus or marantic endocarditis in malignancy).
• Autoimmune conditions: Vasculitis (e.g., SLE, ANCA-associated vasculitis) can present with constitutional symptoms and systemic manifestations.
• Malignancy: Lymphoma or other haematological malignancies could cause fever, weight loss, and night sweats.
• Tuberculosis: Subacute presentation with systemic symptoms should be considered in high-risk populations.

Q2: What investigations are required to confirm the diagnosis?

Key investigations to confirm IE

• Blood cultures (3 sets from different sites, before antibiotics).
• Transthoracic echocardiogram (TTE): Initial imaging to detect vegetations.
• Transoesophageal echocardiogram (TOE): If TTE is inconclusive or prosthetic valves are present.
• Full blood count (FBC): Likely to show normocytic anaemia, leukocytosis.
• Inflammatory markers (CRP, ESR): Expected to be elevated.
• Renal function tests: To assess for septic emboli or drug toxicity.
• Urinalysis: Assess for haematuria or proteinuria, suggestive of glomerulonephritis.
• ECG: Assess for conduction defects suggestive of perivalvular abscess.

Q3: Outline the immediate and long-term management of this patient.

Immediate Management

• Admit to hospital for IV antibiotics and cardiology review.
• Empirical IV antibiotics: Vancomycin + Gentamicin until sensitivities known.
• Monitor for complications: Heart failure, septic emboli (e.g., stroke, renal infarcts).

Long-term Management

• Targeted IV antibiotic therapy for 4-6 weeks based on culture results.
• Valve surgery if indicated (severe regurgitation, abscess, embolic events).
• Risk factor modification: Smoking cessation, substance use counselling.
• Prophylaxis for future procedures: Antibiotic prophylaxis for high-risk patients undergoing invasive dental or surgical procedures.

Q4: How would you communicate the diagnosis and management plan to the patient?

• Diagnosis explanation: “You have a serious heart infection called infective endocarditis. This is likely caused by bacteria entering your bloodstream, possibly after your recent dental procedure.”
• Treatment explanation: “You need urgent admission to hospital for IV antibiotics for at least 4-6 weeks. In some cases, surgery may be required.”
• Address concerns: Assess patient’s understanding, discuss risks of untreated IE.
• Follow-up plan: Arrange for ongoing cardiac monitoring and lifestyle modifications.

Q5: What are the preventive strategies for infective endocarditis?

• Good oral hygiene: Regular dental check-ups to reduce the risk of transient bacteraemia.
• Antibiotic prophylaxis: Recommended for high-risk patients (prosthetic valves, previous IE, congenital heart disease) before invasive dental procedures.
• Substance use support: Harm minimisation strategies for those with past or current IV drug use.
• Vaccination: Annual influenza vaccine and pneumococcal vaccine as per guidelines.

SUMMARY OF A COMPETENT ANSWER

• Correctly identifies infective endocarditis as the most likely diagnosis, using Duke’s criteria.
• Provides a structured differential diagnosis, considering sepsis, malignancy, and autoimmune causes.
• Outlines essential investigations, prioritising blood cultures and echocardiography.
• Describes both immediate and long-term management, including antibiotics, surgical indications, and preventive strategies.
• Communicates effectively with the patient, ensuring understanding and adherence to treatment.

PITFALLS

• Failing to recognise infective endocarditis and delaying referral.
• Not ordering blood cultures before starting antibiotics, reducing diagnostic yield.
• Overlooking the need for echocardiography, particularly TOE in high-risk patients.
• Ignoring preventive strategies, particularly dental hygiene and antibiotic prophylaxis.
• Providing incorrect antibiotic choices (e.g., oral antibiotics instead of IV).

REFERENCES

• 
  RACGP Guidelines on Management of Infective Endocarditis in General Practice
• Australian Prescriber on Infective Endocarditis
• Heart Foundation on Endocarditis Prevention and Management
• Better Health Channel on Infective Endocarditis

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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 history relevant to infective endocarditis.
2.2 Interprets clinical findings suggestive of IE.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies key clinical features of IE.
3.2 Uses Duke’s criteria for diagnosis.

4. Clinical Management and Therapeutic Reasoning

4.1 Initiates appropriate empirical antibiotic therapy.
4.2 Recognises the need for specialist referral.

5. Preventive and Population Health

5.1 Identifies risk factors for IE and implements preventive strategies.

6. Professionalism

6.1 Demonstrates shared decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Understands the need for notification of IE as a serious infection.

8. Procedural Skills

8.1 Recognises the need for blood cultures and echocardiography.

9. Managing Uncertainty

9.1 Balances risk when a definitive diagnosis is unclear.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises the severity of IE and initiates urgent management.

Competency at Fellowship Level

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