Case ID: CCE-2025-RAHF
Case Name: Peter Johnson
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K78 (Atrial Fibrillation), K77 (Heart Failure)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages patient to understand their concerns and expectations 1.2 Communicates effectively with patients and carers about the diagnosis and management plan 1.3 Demonstrates empathy and sensitivity when discussing prognosis and treatment options
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused history to elicit symptoms of atrial fibrillation and heart failure 2.2 Identifies red flag symptoms indicating acute decompensation
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates a differential diagnosis considering other causes of dyspnoea and palpitations 3.2 Assesses the severity of heart failure and risk stratifies atrial fibrillation
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a pharmacological and non-pharmacological management plan 4.2 Decides on appropriate anticoagulation therapy based on risk assessment (e.g., CHA₂DS₂-VASc, HAS-BLED)
5. Preventive and Population Health	5.1 Provides lifestyle advice to manage cardiovascular risk factors 5.2 Plans appropriate follow-up to prevent hospitalisation
6. Professionalism	6.1 Maintains patient autonomy while ensuring safety
7. General Practice Systems and Regulatory Requirements	7.1 Adheres to Medicare regulations for chronic disease management and telehealth use in rural areas
8. Procedural Skills	8.1 Orders and interprets ECG and BNP for heart failure assessment
9. Managing Uncertainty	9.1 Balances the risks and benefits of interventions in an elderly patient with multiple comorbidities
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates urgent management for acute heart failure decompensation
11. Rural Health Context (RH)	RH1.1 Addresses challenges of accessing specialist care in a rural setting RH1.2 Utilises telehealth and local resources for ongoing management

CASE FEATURES

Potential issues with medication adherence and access to healthcare
72-year-old male with a known history of atrial fibrillation and newly diagnosed heart failure
Presents with worsening dyspnoea, palpitations, and mild peripheral oedema
Lives in a remote rural town with limited access to specialist care
Requires anticoagulation consideration, rate vs rhythm control, and heart failure optimisation
Recent hospitalisation for pneumonia, raising concerns about recurrent exacerbations

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take a focused history.
Outline the differential diagnosis and key investigations required.
Discuss the management plan.
Address the patient’s concerns.

SCENARIO

Peter Johnson, a 72-year-old retired farmer from a rural town, presents to your clinic complaining of increasing breathlessness over the past two weeks. He describes waking up at night gasping for air and struggling to walk short distances without becoming winded. He has also noticed occasional palpitations and some swelling in his ankles by the evening.

Peter has a history of atrial fibrillation diagnosed two years ago but has not been consistent with his medication due to side effects and difficulty refilling prescriptions in his remote location. He was recently hospitalised for pneumonia, which has exacerbated his symptoms.

PATIENT RECORD SUMMARY

Patient Details

Name: Peter Johnson
Age: 72
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Metoprolol 25 mg BD (often forgets evening dose)
Apixaban 2.5 mg BD (self-discontinued due to bruising)
Furosemide 40 mg mane (uses PRN for swelling)

Past History

Atrial fibrillation (diagnosed 2 years ago)
Hypertension
Type 2 diabetes mellitus (well controlled on metformin)
Recent pneumonia requiring hospital admission

Social History

Previously worked as a farmer, now retired

Family History

Father had a heart attack at 68
Mother had type 2 diabetes

Smoking

Quit 10 years ago (previous 40-pack-year history)

Alcohol

Drinks 1-2 beers on weekends

Vaccination and Preventative Activities

Up to date with influenza and COVID-19 vaccines

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line

“Doctor, I’ve been feeling really short of breath lately, and my heart keeps racing. I don’t know if my heart is getting worse or if I need stronger medication.”

General Information

Peter is worried about his worsening breathlessness and palpitations.
He has been struggling with daily activities like walking to the mailbox.
He has difficulty accessing his medications consistently due to travel issues.
He is reluctant to go to the hospital again and prefers to manage things locally.
He is anxious about his prognosis and whether he will need to leave his home.

Specific Information

(Only Given If Asked by the Candidate)

Symptoms & Functional Impact

Over the past two weeks, he has noticed increasing breathlessness with mild exertion.
He wakes up at night gasping for air and needs to sit upright to breathe better.
Walking even short distances, like from the kitchen to the lounge, leaves him winded.
He sometimes feels his heart racing unpredictably, which makes him feel uneasy.
He has noticed mild swelling in his ankles that worsens by the evening.

Medication Adherence & Access Issues

He has been prescribed metoprolol twice a day but often forgets to take the evening dose.
He was on apixaban but stopped it a few months ago due to easy bruising.
He takes furosemide, but only when his ankles swell because he doesn’t like going to the toilet frequently.
He struggles with medication access as he has to travel 45 minutes to the nearest pharmacy, and sometimes he forgets to refill his prescriptions.
He is not sure if his medications are working and is wondering if he needs to change them.

Concerns About His Condition

He is worried that his heart is failing and that he may not have long to live.
He wonders if he will need to move to the city to be closer to a hospital.
He wants to know if he really needs to restart his blood thinner, as he doesn’t like the bruising.
He is scared of having a stroke or a heart attack but doesn’t know how serious his condition is.
He wants to avoid being admitted to the hospital again as it was stressful last time.

Lifestyle & Social Situation

He lives alone in a rural town and is independent but finding it harder to manage daily tasks.
His daughter visits once a month, but he doesn’t like to bother her.
He used to enjoy gardening but now finds it too exhausting.
He is concerned about how he will manage if his symptoms get worse.

Emotional & Non-Verbal Cues

Concerned & Worried: Furrows his brow when discussing his prognosis and future.
Anxious About Symptoms: Pauses when describing his breathlessness, as if unsure how bad it is.
Frustrated: Shakes his head slightly when talking about medication side effects and access difficulties.
Fearful About Moving: Voice drops when discussing the possibility of leaving his home.

Potential Questions Peter May Ask the Candidate

“Is my heart getting weaker? Am I going to need a pacemaker?”
(He fears that his heart failure is getting worse and wants to understand his condition.)
“Do I really need to go back on blood thinners? I’m worried about bleeding.”
(He has concerns about anticoagulation and wants reassurance.)
“What can I do to stop this from getting worse?”
(He is looking for lifestyle changes that could improve his condition.)
“Can I still live here, or do I have to move to the city?”
(He is reluctant to leave his home but fears he may not have a choice.)

How Peter Will Respond Based on the Candidate’s Approach

If the candidate explains his condition clearly and reassures him, Peter will seem more at ease and ask more practical questions about his management.
If the candidate pushes for a hospital admission without discussing alternatives, Peter will become resistant and state he wants to avoid going to the hospital again.
If the candidate acknowledges his rural access difficulties, he will open up about his struggles in getting to medical appointments and filling prescriptions.
If the candidate provides options for care that allow him to stay in his community, Peter will show relief and be more engaged in the discussion.

Key Role-Playing Objectives

Encourage the candidate to take a patient-centred approach.
Provide enough detail to allow a thorough assessment of his symptoms and management needs.
Create an opportunity for the candidate to explore social, emotional, and logistical barriers to care in a rural setting.
Assess the candidate’s ability to balance symptom control, medication adherence, and patient preferences while ensuring a safe management plan.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptoms, functional impact, and medication adherence.

The competent candidate should:

Elicit key symptoms related to heart failure and atrial fibrillation, including dyspnoea (exertional and nocturnal), palpitations, ankle swelling, and fatigue.
Assess functional impact by determining activity tolerance, impact on daily activities, and symptom progression over time.
Clarify medication adherence by asking about missed doses, side effects, and access difficulties.
Explore cardiovascular risk factors, including hypertension, diabetes, past cardiac history, and family history of heart disease.
Identify red flag symptoms suggestive of decompensation, such as orthopnoea, paroxysmal nocturnal dyspnoea, worsening oedema, and dizziness or syncope.
Screen for psychosocial factors, including rural access challenges, support networks, and concerns about relocating for care.

Task 2: Explain your working diagnosis and rationale for further investigations or treatment adjustments.

The competent candidate should:

Explain the likely diagnosis of atrial fibrillation with heart failure in clear, layman’s terms.
Describe how atrial fibrillation can contribute to heart failure, using simple language to explain impaired cardiac function and fluid overload.
Discuss the need for further investigations, including:
- ECG (to confirm rhythm and rate control).
- Echocardiogram (to assess left ventricular function and valve disease).
- BNP (to evaluate heart failure severity).
- FBE, UEC, and thyroid function tests (to rule out secondary causes of AF).
Address concerns about stroke risk due to AF and the importance of anticoagulation.
Outline treatment adjustments, including optimising heart failure medications, managing rate control, and reintroducing anticoagulation.

Task 3: Discuss the management plan, including anticoagulation, symptom control, and follow-up.

The competent candidate should:

Explain the need for anticoagulation using CHA₂DS₂-VASc and HAS-BLED scores to balance stroke vs bleeding risk.
Address medication adherence issues, discussing ways to manage side effects and medication access in a rural setting.
Optimise heart failure treatment, adjusting:
- Beta-blockers (e.g., metoprolol) to control AF rate.
- Diuretics (e.g., furosemide) for symptom relief.
- ACE inhibitors/ARNIs to improve cardiac function.
Recommend lifestyle modifications, such as fluid and salt restriction, weight monitoring, and smoking/alcohol reduction.
Establish a follow-up plan, including telehealth check-ins, specialist referrals, and escalation criteria for seeking urgent care.

Task 4: Address the patient’s concerns about their condition, prognosis, and access to care.

The competent candidate should:

Acknowledge Peter’s fears about worsening health and the impact on his independence.
Provide realistic but reassuring information about heart failure being manageable with proper treatment.
Explore alternative care options, such as local outreach cardiology, telehealth consultations, and home medication delivery services.
Discuss contingency planning, advising when to seek urgent medical attention.
Empower Peter with strategies for self-monitoring and early intervention.

SUMMARY OF A COMPETENT ANSWER

Demonstrates a structured history-taking approach, addressing symptoms, functional impact, and medication adherence.
Clearly explains the diagnosis, linking atrial fibrillation and heart failure in an understandable way.
Uses evidence-based decision-making for investigations, anticoagulation, and medication optimisation.
Acknowledges rural healthcare challenges, offering practical solutions for medication access and follow-up care.
Provides patient-centred education and reassurance, addressing concerns about prognosis and quality of life.

PITFALLS

Failing to assess functional impact, leading to underestimation of symptom severity.
Overlooking medication adherence issues, missing key barriers like side effects and rural access challenges.
Providing a vague diagnosis, rather than explaining how atrial fibrillation and heart failure interact.
Neglecting stroke risk assessment, failing to justify anticoagulation decisions.
Not addressing psychosocial concerns, leaving Peter feeling uncertain about his future and care options.

REFERENCES

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.
1.3 Demonstrates empathy and sensitivity when discussing prognosis and treatment options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused history to elicit symptoms of atrial fibrillation and heart failure.
2.2 Identifies red flag symptoms indicating acute decompensation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a differential diagnosis considering other causes of dyspnoea and palpitations.
3.2 Assesses the severity of heart failure and risk stratifies atrial fibrillation.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a pharmacological and non-pharmacological management plan.
4.2 Decides on appropriate anticoagulation therapy based on risk assessment (e.g., CHA₂DS₂-VASc, HAS-BLED).

5. Preventive and Population Health

5.1 Provides lifestyle advice to manage cardiovascular risk factors.
5.2 Plans appropriate follow-up to prevent hospitalisation.

6. Professionalism

6.1 Maintains patient autonomy while ensuring safety.

7. General Practice Systems and Regulatory Requirements

7.1 Adheres to Medicare regulations for chronic disease management and telehealth use in rural areas.

8. Procedural Skills

8.1 Orders and interprets ECG and BNP for heart failure assessment.

9. Managing Uncertainty

9.1 Balances the risks and benefits of interventions in an elderly patient with multiple comorbidities.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates urgent management for acute heart failure decompensation.

11. Rural Health Context (RH)

RH1.1 Addresses challenges of accessing specialist care in a rural setting.
RH1.2 Utilises telehealth and local resources for ongoing management.

Competency at Fellowship Level

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