CASE INFORMATION

Case ID: CCE-2025-003
Case Name: Daniel Robertson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K04 (Palpitations), K78 (Atrial fibrillation), K86 (Hypertension), P02 (Stress-related symptoms)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a respectful and empathetic therapeutic relationship 1.2 Effectively gathers information about symptoms, concerns, and expectations 1.4 Communicates effectively in routine and difficult situations
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured and thorough history to identify red flags 2.2 Interprets findings to differentiate between benign and serious causes of palpitations
3. Diagnosis, Decision-Making and Reasoning	3.1 Generates a differential diagnosis for palpitations 3.2 Identifies red flag symptoms suggestive of serious cardiac conditions
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan for palpitations 4.2 Provides appropriate referrals and follow-up based on risk stratification
5. Preventive and Population Health	5.1 Discusses cardiovascular risk reduction and lifestyle modifications
6. Professionalism	6.1 Respects patient autonomy and confidentiality when discussing health concerns
7. General Practice Systems and Regulatory Requirements	7.1 Orders appropriate investigations under Medicare guidelines and refers as needed
8. Procedural Skills	8.1 Explains the indications for and process of ECG and Holter monitoring
9. Managing Uncertainty	9.1 Provides a structured approach to managing palpitations when the cause is unclear
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises red flags for cardiac arrhythmias and refers urgently if indicated

CASE FEATURES

45-year-old male presenting with intermittent palpitations over the past month.
Key differentials: Atrial fibrillation, ectopic beats, supraventricular tachycardia (SVT), anxiety-related palpitations, hyperthyroidism, medication-related effects.
Red flags: Chest pain, dizziness, syncope, shortness of breath, exertional symptoms, family history of sudden cardiac death.
Need for appropriate risk stratification and investigations, including ECG, Holter monitoring, thyroid function tests, and cardiovascular assessment.
Importance of lifestyle modifications and cardiovascular risk reduction.

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

Daniel Robertson, a 45-year-old accountant, presents to your general practice complaining of palpitations that started one month ago. He describes a fast, irregular heartbeat that occurs randomly, lasting a few minutes before resolving. The episodes happen several times a week, sometimes when at rest and sometimes after coffee or alcohol.

He is worried that these palpitations might indicate a heart problem and wants to know if he needs further tests.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Robertson
Age: 45
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

None

Past History

Borderline hypertension, not on treatment

Social History

Works as an accountant, high stress, long hours

Family History

Father died suddenly at 52 (presumed cardiac cause)

Smoking

Never smoked

Alcohol

Increased recently (3-4 drinks on weekends)

Vaccination and Preventative Activities

Influenza vaccine up to date

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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I keep getting these weird heart flutters, and I’m really worried it’s something serious.”

General Information

You first noticed the palpitations about a month ago, and they seem to be happening a few times a week.
The sensation is like your heart is skipping a beat or suddenly racing, and it lasts for a few minutes before settling.
You sometimes feel your heart pounding in your chest, especially when you’re lying down.
The episodes are unpredictable—they can happen at rest, but also sometimes after coffee, alcohol, or stress at work.

Specific Information

(Only reveal when asked directly)

Background Information

You do not have chest pain, fainting, or severe shortness of breath, but you have felt a bit lightheaded during some episodes.
You have been under a lot of stress at work, dealing with deadlines and pressure from clients.
Your father died suddenly at 52, which worries you. You don’t know if it was a heart attack or something else.
You are not on any medications, but you drink more coffee than usual lately—about four to five cups a day—and have been drinking alcohol more often on weekends.
You are concerned this could be a serious heart problem and want to know if you need tests.

Palpitations & Associated Symptoms

You sometimes feel a little lightheaded during an episode, but never fainted.
You have not had any blackouts, dizziness that lasts long, or confusion.
You do not feel breathless during an episode, but you are aware of your heartbeat.
You do not wake up gasping for air at night.
You do not feel pressure or pain in your chest.
The palpitations do not always happen with exertion, and you have not noticed them during exercise.
You have no leg swelling, nausea, or cold sweats.

Lifestyle & Triggers

You work long hours as an accountant and sit at a desk most of the day.
You haven’t been exercising much lately.
Your diet hasn’t been great, and you have gained about 5 kg in the last year.
You have been drinking more coffee than usual—four to five cups a day.
You drink about three to four alcoholic drinks on weekends, which is more than usual.
You do not use energy drinks, drugs, or smoke.

Past Medical & Family History

You have never had high blood pressure or cholesterol checks, and you are unsure if your father had heart disease.
You do not have diabetes, thyroid issues, or known heart conditions.
You have never had an ECG or heart check-up before.

Emotional Cues

You are worried about your father’s sudden death and fear this could be a sign of a heart condition.
You feel anxious during episodes, which sometimes makes them seem worse.
If the doctor dismisses your symptoms, you become frustrated and insist on testing.
If the doctor provides a structured plan, you feel more reassured.

Patient Concerns and Expectations

“Do I need an ECG or heart scan?“ – You want to rule out a heart condition.
“Could this be serious?” – You worry about arrhythmias or hidden heart disease.
“Is this caused by stress, or do I have a heart problem?“ – You’re unsure if lifestyle factors or an underlying condition are responsible.
“Do I need to see a heart specialist?” – You want to know if referral to a cardiologist is necessary.
“How can I stop this from happening again?“ – You want practical advice on management and prevention.

Questions for the Candidate

“Is this something I should be really worried about?”
“What exactly causes palpitations?”
“If my heart is skipping beats, does that mean I have an arrhythmia?”
“Could this be related to my father’s sudden death?”
“What tests do I need to rule out something serious?”
“Can stress really cause this, or is that just an excuse?”
“Do I need medication to control this?”
“What lifestyle changes would help?”

Role-Player Behaviour During Consultation

If the candidate takes a thorough history and explains their reasoning well, you feel reassured and open to their advice.
If the candidate dismisses your concerns too quickly, you become more persistent and push for more tests.
If the candidate provides a structured explanation and management plan, you respond positively and ask about next steps.
If the candidate seems unsure or vague about testing or referral, you express frustration and ask if you should see a specialist.

Role-Player Goals

Push for clear explanations about your symptoms and possible causes.
Express concern about family history and ask if this puts you at higher risk.
Insist on testing if the candidate is dismissive.
React positively to a structured plan but challenge vague reassurances.
Expect the candidate to discuss lifestyle factors and ways to prevent palpitations.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering red flags and risk factors.

The competent candidate should:

Establish rapport and conduct an empathetic, patient-centred consultation, addressing the patient’s concern about a serious heart condition.
Clarify the characteristics of the palpitations, including:
- Onset, duration, frequency, and triggers (e.g., at rest, with caffeine, alcohol, exertion).
- Nature of the palpitations (rapid, irregular, skipping beats, pounding).
- Associated symptoms: chest pain, syncope, dizziness, shortness of breath, nausea, sweating.
- Aggravating and relieving factors.
Explore cardiovascular risk factors:
- Hypertension, diabetes, hyperlipidaemia, smoking, family history of cardiac disease.
- Recent lifestyle changes, including caffeine, alcohol, stress, and physical inactivity.
Assess for red flags:
- Family history of sudden cardiac death.
- Exertional palpitations associated with dizziness or syncope.
- Episodes lasting longer than a few minutes with ongoing symptoms.
Consider non-cardiac causes, including anxiety, hyperthyroidism, medication effects, and anaemia.
Summarise findings and address the patient’s concerns while outlining the need for further assessment.

Task 2: Discuss the differential diagnoses and explain potential causes of his palpitations.

The competent candidate should:

Explain that palpitations can arise from benign, physiological, or serious cardiac causes.
Discuss common benign causes:
- Anxiety-related palpitations – often associated with stress, work pressure, and panic symptoms.
- Excess caffeine or alcohol intake – known triggers for ectopic beats and supraventricular tachycardia (SVT).
- Lifestyle-related factors – poor sleep, dehydration, and lack of exercise.
Explain cardiac-related causes:
- Atrial fibrillation (AF) – irregular, rapid heartbeat, more common with age and hypertension.
- SVT – sudden onset and offset of rapid heart rate, sometimes with dizziness.
- Ventricular ectopy – skipped beats, common in stress and fatigue.
- Structural heart disease – may present with exertional symptoms, syncope, or family history of sudden cardiac death.
Discuss non-cardiac causes:
- Hyperthyroidism – weight loss, tremors, heat intolerance, anxiety.
- Anaemia – fatigue, shortness of breath, pallor.
- Electrolyte imbalance – recent dehydration, diuretic use, vomiting/diarrhoea.
Use patient-friendly language, reassuring the patient that while some causes are benign, further evaluation is essential.

Task 3: Outline an appropriate management plan, including necessary investigations and referrals.

The competent candidate should:

Explain the need for investigations to assess the cause and rule out serious conditions.
Order first-line tests:
- 12-lead ECG – to check for arrhythmias, conduction delays, or signs of previous cardiac disease.
- Holter monitoring (24-48 hours) – if palpitations are frequent but not captured on ECG.
- Full blood count (FBC) – to rule out anaemia.
- Thyroid function tests (TFTs) – to assess for hyperthyroidism.
- Electrolytes (U&Es, magnesium, calcium) – to identify imbalances that may contribute to palpitations.
Arrange cardiology referral if red flags are present, such as:
- Family history of sudden cardiac death.
- Exertional palpitations with dizziness/syncope.
- ECG abnormalities (e.g., prolonged QT, frequent ectopy, atrial fibrillation).
Symptom management:
- Encourage stress reduction techniques (e.g., mindfulness, exercise).
- Advise reducing caffeine and alcohol.
- Consider beta-blockers if symptoms persist and are bothersome.
Schedule follow-up within 1-2 weeks to review results and plan further action.

Task 4: Provide preventive health advice regarding cardiovascular risk and lifestyle modifications.

The competent candidate should:

Educate the patient on cardiovascular risk factors, including:
- Hypertension and weight gain, which increase the risk of atrial fibrillation and other arrhythmias.
- Family history of heart disease as a potential risk factor for early cardiac events.
Lifestyle modifications:
- Reduce caffeine and alcohol intake.
- Increase regular exercise (≥150 minutes per week).
- Improve diet – limit processed foods, increase fruits/vegetables.
- Manage stress through relaxation techniques.
Smoking and alcohol cessation support if relevant.
Routine cardiovascular screening:
- Blood pressure and cholesterol checks.
- Consider a cardiovascular risk assessment (e.g., absolute CVD risk calculator).
Encourage regular medical follow-up and symptom monitoring.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, identifying red flags, triggers, and cardiovascular risk factors.
Clear and structured differential diagnosis, considering both benign and serious causes.
Logical investigation plan, including ECG, Holter monitoring, and relevant blood tests.
Appropriate management and referral, ensuring high-risk patients receive timely cardiology review.
Patient-centred communication, addressing concerns, using lay language, and offering reassurance.
Preventive health approach, emphasising lifestyle modifications and cardiovascular risk reduction.

PITFALLS

Failing to identify red flags, such as exertional symptoms, syncope, and family history of sudden cardiac death.
Over-reassuring without adequate investigation, potentially missing a serious underlying cause.
Not ordering an ECG, which is essential for initial evaluation of arrhythmias.
Neglecting non-cardiac causes, such as hyperthyroidism, anaemia, or electrolyte imbalance.
Failing to provide preventive advice, missing an opportunity for cardiovascular risk reduction.
Using excessive medical jargon, leading to poor patient understanding and increased anxiety.

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured and thorough history to identify red flags.
2.2 Interprets findings to differentiate between benign and serious causes of palpitations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates a differential diagnosis for palpitations.
3.2 Identifies alarm symptoms suggestive of serious conditions.

Competency at Fellowship Level

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