CASE INFORMATION

Case ID: CCE-2025-001
Case Name: John Mitchell
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K99 (Adverse effect of medical treatment), D17 (Gastrointestinal bleeding)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages empathetically 1.2 Explains clinical information effectively 1.5 Negotiates a shared management plan
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant medical history 2.2 Interprets medication effects and interactions
3. Diagnosis, Decision-Making, and Reasoning	3.1 Identifies red flag symptoms 3.3 Forms a reasonable differential diagnosis
4. Clinical Management and Therapeutic Reasoning	4.2 Adjusts medication based on adverse effects 4.5 Provides immediate safety measures
5. Preventive and Population Health	5.3 Provides education on medication risks
6. Professionalism	6.2 Recognises and manages adverse drug events responsibly
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and reporting of adverse effects
9. Managing Uncertainty	9.2 Balances risks of ongoing treatment with patient safety
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on potentially life-threatening conditions

CASE FEATURES

Elderly patient with a recent prescription of apixaban (Eliquis) for atrial fibrillation.
Now presenting with melena and dizziness.
No prior history of gastrointestinal bleeding.
Patient’s INR and coagulation profile need assessment.
Discussion required regarding risk-benefit balance of continuing anticoagulation.
Need for urgent hospital referral and coordination with specialists.

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 an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

John Mitchell, a 72-year-old retired teacher, presents with black tarry stools and dizziness for the past 24 hours. He started taking apixaban one week ago after a recent diagnosis of atrial fibrillation. He denies abdominal pain, nausea, or vomiting but mentions feeling weak and lightheaded when standing.

You have access to his patient record, which shows that he has hypertension, mild chronic kidney disease (eGFR 55 mL/min), and no prior history of gastrointestinal ulcers or bleeding. His BP today is 100/65 mmHg, HR 98 bpm (irregular), and he looks pale.

PATIENT RECORD SUMMARY

Patient Details

Name: John Mitchell
Age: 72
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Apixaban 5 mg BD (started 1 week ago)
Amlodipine 5 mg OD
Atorvastatin 40 mg OD

Past History

Atrial fibrillation (paroxysmal) – diagnosed 1 week ago
Hypertension – well controlled
Chronic kidney disease (Stage 3a, eGFR 55 mL/min)

Social History

Lives alone, independent in ADLs.
No smoking, drinks 1-2 glasses of wine per week.

Family History

Father had a stroke at 75.

Smoking & Alcohol

Non-smoker.
Alcohol: Occasional wine.

Vaccination & Preventative Activities

Flu vaccine up to date.
Colonoscopy 3 years ago – normal.

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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve been feeling really dizzy and noticed my stool is black… Could it be the new blood thinner?”

General Information

You started taking apixaban 5 mg twice daily about a week ago after being diagnosed with atrial fibrillation.
Your cardiologist prescribed it to reduce your stroke risk, and you were told it was a safer alternative to warfarin.
You live alone and manage your daily activities independently.
You have never had stomach ulcers, reflux, or previous gastrointestinal bleeding.
Your appetite has been normal, and you haven’t noticed any vomiting or nausea.

Specific Information

(Reveal Only When Asked)

Symptoms

Since yesterday morning, you have noticed your stools are black and sticky. You looked it up online and read that it could be internal bleeding, which made you worried.
You have felt lightheaded and dizzy, especially when standing up. You even had to sit down while brushing your teeth this morning because you felt unsteady.
You do not have any stomach pain but feel generally weaker than usual.
No vomiting, but you did feel a bit queasy this morning.

Medication History

You take amlodipine for high blood pressure and atorvastatin for cholesterol.
You have never taken aspirin or NSAIDs like ibuprofen because you were told they could cause stomach issues.
You don’t take any herbal supplements.

Bowel and Urinary History

Your bowels have been regular until yesterday. The black stools started suddenly.
You have not had diarrhoea, constipation, or recent changes in bowel habits.
You might be urinating more frequently, but you aren’t sure—it could just be that you drink a lot of water.

Social and Emotional Context

You live alone but have a daughter who checks in on you every few days.
You have no history of falls or head injuries.
You don’t smoke and drink one or two glasses of wine a week.
You are worried about stopping the apixaban because the cardiologist told you it’s essential to prevent a stroke.
You feel frustrated because you trusted that this was a safe medication, and now you are experiencing serious side effects.

Emotional Cues

Anxiety: You seem nervous, fidgeting with your hands while speaking.
Frustration: Your voice may rise slightly when discussing the medication side effects.
Fear: You express concern that you might collapse at home alone.
Uncertainty: You pause before answering questions about what you should do next, hoping the doctor will reassure you.

Key Questions for the Candidate

(Ask these in a conversational manner, especially if the doctor has not already addressed them.)

“Is this serious? Do I need to go to the hospital?” (You are hoping the doctor reassures you, but you also want an honest answer.)
“Does this mean I can never take blood thinners again? If I stop this, am I at a high risk of stroke?” (You are aware that blood thinners are necessary, but you are afraid of having another complication.)
“What tests do I need? Do I have to stop taking my medication right away?” (You want to know if stopping the medication will be safe for you.)
“Can this be treated without going to the hospital? I don’t really want to go unless it’s absolutely necessary.” (You are hesitant about hospital admission but open to being convinced if needed.)
“Why didn’t my cardiologist warn me this could happen?” (You feel frustrated that you were not fully informed about possible side effects.)

Possible Patient Reactions Based on the Candidate’s Response

If the Doctor Reassures You That the Hospital is Necessary

You sigh but nod. “I suppose you’re right. I don’t want to take any chances.”
You may ask, “Will they keep me in overnight?”

If the Doctor Suggests Stopping Apixaban Without Alternative Measures

You frown and ask, “But won’t that mean my stroke risk goes up? What if I get another clot?”
If the doctor does not mention follow-up with a specialist, you might say: “Shouldn’t my cardiologist be involved in this decision?”

If the Doctor is Uncertain or Hesitant About Management

You raise an eyebrow and say, “Doctor, I need to know what to do now. I can’t just wait and see, right?”

Role-Player’s Objective

Encourage the candidate to take a structured approach: history-taking, explaining risks, and offering a clear management plan.
Assess the candidate’s ability to communicate effectively, ensuring you feel heard and informed.
Observe if the candidate manages your emotional state appropriately—do they acknowledge your fear and frustration?
Determine if the candidate ensures your immediate safety—do they arrange for a hospital referral and coordinate care with your cardiologist?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history from the patient regarding symptoms and medication use.

The competent candidate should:

Establish rapport and acknowledge the patient’s concerns and anxiety.
Take a structured history, including:
- Symptom onset and progression (when did the black stools start? Any associated dizziness or weakness?).
- Gastrointestinal history (prior ulcers, reflux, gastrointestinal bleeding, changes in appetite).
- Medication history, particularly apixaban and any NSAIDs or over-the-counter drugs.
- Social history, including alcohol intake, diet, and support at home.
- Red flags such as syncope, haematemesis, severe hypotension.
Explore the patient’s understanding of anticoagulation therapy and address any concerns regarding stroke risk vs bleeding risk.

Task 2: Explain the possible cause of the symptoms and discuss the next steps.

The competent candidate should:

Explain in clear, non-medical language that the black stools (melena) indicate upper gastrointestinal bleeding, likely due to apixaban use.
Reassure the patient while emphasising the serious nature of the condition.
Outline the likely cause (apixaban-induced GI bleed), but acknowledge that further investigations are required to confirm the source.
Advise urgent referral to hospital for further management, including blood tests (FBC, UEC, LFTs, INR/anti-Xa level) and possible endoscopy.
Address concerns regarding stroke risk by explaining that anticoagulation may need adjustment rather than complete cessation.

Task 3: Outline your management plan, ensuring patient safety.

The competent candidate should:

Arrange immediate hospital referral due to the risk of haemodynamic instability and ongoing bleeding.
Advise cessation of apixaban until specialist review.
Communicate the need for fluid resuscitation, blood transfusion (if required), and gastroenterology assessment.
Discuss potential future modifications to anticoagulation, such as lower dosing, switching to warfarin, or considering a left atrial appendage closure.
Ensure appropriate handover to the emergency department and notify the patient’s cardiologist for ongoing care.

Task 4: Address the patient’s concerns regarding his anticoagulant therapy.

The competent candidate should:

Acknowledge the patient’s fear of stroke and validate their concerns.
Explain the risk-benefit balance of anticoagulation, noting that stroke prevention is critical, but bleeding risks must be managed.
Reassure the patient that options exist for safer anticoagulation, including:
- Adjusting dosage or switching agents.
- Adding a proton pump inhibitor (PPI) for gastroprotection.
- Exploring non-pharmacological interventions, such as left atrial appendage occlusion.
Offer clear guidance on follow-up care and the role of the cardiologist and gastroenterologist in future decisions.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history including symptom timeline, medication use, and relevant risk factors.
Communicates clearly and empathetically, acknowledging patient fears while maintaining clinical authority.
Recognises melena as a medical emergency and initiates urgent referral.
Explains the diagnosis and management plan effectively, including hospital care, investigations, and potential changes to anticoagulation.
Balances patient safety and autonomy, addressing both bleeding and stroke risk concerns.
Demonstrates awareness of Australian guidelines, including anticoagulation management strategies in bleeding patients.

PITFALLS

Failing to recognise melena as a serious complication and not referring the patient to hospital.
Providing vague or overly complex explanations, leaving the patient confused about their condition and management.
Not exploring medication history thoroughly, especially other potential contributors like NSAIDs or alcohol.
Neglecting to address stroke risk—patients may assume stopping anticoagulation indefinitely is an option.
Overlooking the importance of specialist involvement, particularly the need for gastroenterology and cardiology follow-up.
Not considering long-term preventive strategies, such as PPIs or alternative anticoagulation methods.

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

Competency Areas Assessed

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 relevant medical history and identifies potential contributing factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises and prioritises red flag symptoms.
3.3 Demonstrates sound reasoning in identifying a likely diagnosis and outlining next steps.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an appropriate and safe management plan based on the patient’s needs.
4.5 Recognises the urgency of the condition and ensures patient safety.

5. Preventive and Population Health

5.3 Provides education on medication risks and strategies to prevent recurrence.

6. Professionalism

6.2 Recognises and manages adverse drug events responsibly.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and reporting of adverse effects.

9. Managing Uncertainty

9.2 Balances risks of ongoing treatment with patient safety.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on potentially life-threatening conditions.

Competency at Fellowship Level

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