CASE INFORMATION

Case ID: CCE-2025-004
Case Name: John Matthews
Age: 67 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K99 (Cardiac arrhythmia NOS), K78 (Atrial fibrillation/flutter), K89 (Hypertension)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their ideas, concerns, and expectations. 1.2 Develops a respectful and empathetic doctor-patient relationship. 1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including systemic and red flag symptoms. 2.2 Selects and interprets appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings. 3.5 Identifies red flag symptoms requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates a safe and evidence-based management plan. 4.3 Provides appropriate follow-up and monitoring.
5. Preventive and Population Health	5.2 Addresses modifiable risk factors for cardiovascular disease.
6. Professionalism	6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements	7.1 Orders appropriate tests in accordance with MBS guidelines.
9. Managing Uncertainty	9.2 Develops a plan for a patient with an unclear diagnosis.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on life-threatening conditions.

CASE FEATURES

Elderly male presenting with episodes of palpitations, dizziness, and shortness of breath.
Symptoms have been intermittent for the past two months.
He has hypertension and a history of mild heart failure, managed with medication.
No previous formal diagnosis of atrial fibrillation or other arrhythmias.
Concerned about whether his symptoms indicate something serious.
Requires clinical reasoning to differentiate between benign palpitations, atrial fibrillation, other arrhythmias, and cardiac causes of dizziness.

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 Matthews, a 67-year-old retired male, presents to your clinic complaining of episodes of palpitations, dizziness, and shortness of breath that have been occurring intermittently for the past two months. He describes them as a racing heartbeat that lasts for several minutes to an hour, sometimes associated with lightheadedness and mild breathlessness.

John is worried that these episodes might be serious, like a heart attack or stroke. He has no chest pain, syncope, or leg swelling, but he wants to know what is causing this and what needs to be done.

PATIENT RECORD SUMMARY

Patient Details

Name: John Matthews
Age: 67 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Perindopril 4 mg daily (Hypertension)
Bisoprolol 2.5 mg daily (Heart failure)

Past History

Hypertension (diagnosed 15 years ago)
Mild heart failure (diagnosed 3 years ago, stable)

Social History

Retired electrician, lives with wife.
Former smoker, quit 10 years ago (20 pack-year history).
Drinks 2-3 standard drinks per week.

Family History

Father: Died at 72 from a heart attack.
Mother: Alive, hypertension.
No family history of arrhythmias or strokes.

Vaccination and Preventative Activities

Up to date with vaccinations.
Last health check one year ago.

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 getting these episodes where my heart races, and I feel a bit dizzy and short of breath. It’s been happening on and off for a couple of months now. I’m starting to get worried.”

General Information

(Freely Shared if Asked Open-Ended Questions)

You first noticed these episodes of heart racing about two months ago.
At first, they were mild and occasional, but now they seem to be happening a few times a week.
The sensation feels like your heart is pounding fast and irregularly.
The episodes last between a few minutes and up to an hour, then resolve on their own.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

You sometimes feel dizzy or lightheaded when it happens, especially if you are standing or walking.
You feel a bit short of breath during the episodes, but you don’t feel like you’re gasping for air.
You haven’t had any fainting or loss of consciousness.
You haven’t had any chest pain, nausea, sweating, or jaw pain.
The episodes seem to come on randomly, but sometimes they happen when walking uphill, after drinking coffee, or when feeling stressed.
You have not tried any medications or remedies to stop them.
You have never had anything like this before.

Symptoms and Triggers

The palpitations feel irregular rather than steady.
You sometimes feel your pulse is too fast to count during an episode.
You have no fever, chills, or signs of infection.
You are not particularly stressed, though you occasionally feel anxious about your health.
You sometimes feel more fatigued than usual, but you attributed it to aging.

Cardiovascular History and Risk Factors

You were diagnosed with hypertension 15 years ago and have been taking perindopril for it.
You were diagnosed with mild heart failure three years ago and were started on bisoprolol.
You have never had a heart attack, stroke, or any known arrhythmias before.
You quit smoking 10 years ago after smoking for 20 years.
You drink 2-3 standard drinks per week.
You have no history of illicit drug use.
You occasionally drink coffee, but not excessively.
Your father died of a heart attack at 72, and your mother has hypertension.

Medication and Compliance

You take your medications every day, but you haven’t checked your blood pressure at home recently.
You have not started any new medications or supplements recently.
You have never taken any medications for heart rhythm issues before.

Physical Activity and Lifestyle

You try to walk daily for exercise, but you’ve started avoiding long walks because you worry about your heart.
You have not noticed swelling in your legs or worsening breathlessness when lying flat.
You feel fine in between episodes, with no persistent fatigue or weakness.

Emotional Cues & Concerns

You are worried that this could be a heart attack or a stroke.
You feel anxious when the episodes happen and wonder if you should go to the hospital.
You are frustrated because you thought your heart condition was well controlled.
You want to know if you should stop exercising or if that would make things worse.
You feel worried about your future health and whether this means something serious like a pacemaker or surgery.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Could this be serious? Am I at risk of a heart attack or stroke?”
“What tests do I need? Should I be going to the hospital?”
“If I need treatment, what are my options?”
“Do I need to change my medications?”
“Can I still go for my daily walks, or should I stop exercising?”
“Will this go away on its own, or is it something I’ll have for the rest of my life?”
“Could this be caused by my blood pressure tablets?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel relieved but still slightly anxious.
You might ask for clarification on next steps:
- “So, you think it’s more likely an arrhythmia than a heart attack?”
- “And if I follow the plan, I should feel better?”
You agree to the investigations and follow-up plan.

If the Candidate is Unclear or Dismissive:

You become more anxious and insistent on further testing.
You might push for urgent tests or a referral to a cardiologist:
- “I just don’t want to take any chances. Can we do all the tests now?”
- “If this gets worse, should I go to the hospital?”
- “I need to know for sure what’s going on.”

Ending the Consultation

If the Candidate Has Done Well:

You feel somewhat reassured and agree to the plan.
You might still confirm:
- “So, I should come back in two weeks unless something changes?”
- “You’ll call me when the test results are in?”
You thank the doctor and leave with a clear idea of what to do next.

If the Candidate Has Not Addressed Your Concerns Well:

You remain doubtful and uneasy.
You may say:
- “I think I might get a second opinion. I just want to be sure.”
- “I’m still not sure if this is something serious.”
You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including red flag symptoms and relevant risk factors.

The competent candidate should:

Use open-ended questions initially, then transition to targeted questions about the palpitations, including onset, duration, frequency, severity, and associated symptoms.
Clarify the nature of the palpitations (regular vs irregular, fast vs slow).
Identify red flag symptoms, including syncope, chest pain, sudden shortness of breath, haemodynamic instability, or neurological symptoms.
Explore triggers such as exertion, stress, caffeine, alcohol, medication changes, or recent illness.
Review cardiovascular history, including hypertension, heart failure, previous arrhythmias, and past cardiac events.
Assess medication adherence and potential side effects, particularly beta-blockers and antihypertensives.
Evaluate family history of arrhythmias, sudden cardiac death, or stroke.
Address lifestyle factors, including exercise tolerance, smoking, alcohol intake, and stimulant use.
Determine patient’s concerns and expectations, particularly regarding the risk of heart attack or stroke.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain that arrhythmias can arise from various underlying causes and that further assessment is required to determine the exact type.
Discuss likely differentials:
- Atrial fibrillation (AF): Irregular palpitations, common in older adults with hypertension and heart disease.
- Supraventricular tachycardia (SVT): Sudden-onset fast palpitations, sometimes triggered by exertion or stimulants.
- Ventricular ectopics or tachycardia: Possible in patients with heart disease, may cause dizziness or syncope.
- Sinus tachycardia due to physiological stress: Often caused by anxiety, infection, dehydration, or medications.
- Bradyarrhythmias: Less likely but should be considered if episodes are associated with dizziness or presyncope.
Explain the importance of identifying serious arrhythmias and ruling out underlying structural heart disease.
Reassure the patient that with appropriate testing and management, most arrhythmias can be controlled.

Task 3: Explain the investigations you will request and why.

The competent candidate should:

Justify initial investigations, including:
- Resting ECG: To check for atrial fibrillation, conduction delays, or ectopic beats.
- 24-hour Holter monitor or event recorder: If symptoms are intermittent and not captured on ECG.
- Echocardiogram: To assess for structural heart disease and left ventricular function.
- Full blood count (FBC), electrolytes, thyroid function tests (TFTs): To rule out anaemia, electrolyte disturbances, or hyperthyroidism as causes of arrhythmia.
- B-type natriuretic peptide (BNP): If worsening heart failure is suspected.
Explain that if high-risk features are present (e.g., syncope, severe breathlessness), urgent referral to a cardiologist or ED assessment may be required.
Provide a clear follow-up plan based on test results.

Task 4: Provide an initial management plan and follow-up advice.

The competent candidate should:

Develop a management plan tailored to the likely arrhythmia:
- If atrial fibrillation is confirmed: Rate control (e.g., beta-blockers), stroke risk assessment (CHA₂DS₂-VASc score), and consideration of anticoagulation.
- If SVT is suspected: Lifestyle modifications (avoiding triggers), vagal manoeuvres, and cardiology referral.
- If ventricular ectopics are likely: Reassurance if benign, but further cardiology assessment if symptoms worsen.
- If structural heart disease is identified: Optimisation of heart failure management and cardiology referral.
Address modifiable risk factors, including hypertension control, weight management, smoking cessation, and limiting alcohol/caffeine.
Advise when to seek urgent care, such as chest pain, syncope, or worsening breathlessness.
Arrange follow-up in 1-2 weeks to review test results and symptom progression.

SUMMARY OF A COMPETENT ANSWER

Takes a structured, patient-centred history, addressing red flags, triggers, and risk factors.
Provides a clear and logical differential diagnosis, explaining benign vs serious arrhythmias.
Orders appropriate investigations, including ECG, Holter monitoring, and blood tests.
Develops a safe, evidence-based management plan, with clear safety-netting advice.
Uses empathetic and reassuring communication, addressing the patient’s concerns about heart attack and stroke.

PITFALLS

Failure to elicit red flag symptoms, such as syncope or chest pain.
Over-reassurance without investigations, leading to missed arrhythmias.
Not considering serious arrhythmias like atrial fibrillation or ventricular tachycardia.
Omitting a structured approach to stroke risk assessment in suspected AF cases.
Lack of clear safety-netting, leaving the patient unsure of when to seek urgent care.

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 Gathers and interprets relevant history, including red flags.
2.2 Selects and justifies appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on history and findings.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and safety-netting.

5. Preventive and Population Health

5.2 Addresses modifiable risk factors for cardiovascular disease.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate tests in line with MBS guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on potentially serious conditions.

Competency at Fellowship Level

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