CASE INFORMATION

Case ID: CCE-CE-013
Case Name: Daniel Carter
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K71 (Endocarditis), A04 (Fatigue), L04 (Fever), K76 (Heart Murmur)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Uses active listening and empathy to explore the patient’s illness experience 1.5 Provides clear and sensitive explanations of potential diagnoses and required investigations
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to assess risk factors for infective endocarditis 2.2 Identifies red flags for severe infection and cardiac complications 2.3 Orders and interprets appropriate investigations for suspected infective endocarditis
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of infective endocarditis and considers it in the differential diagnosis 3.3 Differentiates between infective endocarditis and alternative causes of fever and systemic illness
4. Clinical Management and Therapeutic Reasoning	4.2 Initiates urgent referral for hospitalisation and specialist input 4.4 Ensures appropriate empirical antibiotic therapy is commenced
5. Preventive and Population Health	5.2 Provides education on risk factors, including dental hygiene and intravenous drug use
6. Professionalism	6.2 Demonstrates sensitivity in discussing a potentially life-threatening illness
7. General Practice Systems and Regulatory Requirements	7.1 Ensures timely referral to appropriate healthcare services
9. Managing Uncertainty	9.1 Addresses patient concerns about the seriousness of their condition and potential complications
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates urgent management for suspected infective endocarditis

CASE FEATURES

Concerned that he’s been unwell for weeks and is not improving.
45-year-old male presenting with persistent fever, fatigue, and weight loss.
Past history of mitral valve prolapse with a known murmur.
Recent dental procedure 4 weeks ago without antibiotic prophylaxis.
Complains of night sweats, malaise, and intermittent joint pain.
Developed shortness of breath and mild swelling in the ankles.

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 Carter, a 45-year-old accountant, presents to your general practice with a persistent fever for the past three weeks, associated with fatigue, night sweats, and unintentional weight loss.

He recently had a dental procedure (tooth extraction) four weeks ago, and no antibiotics were given beforehand.

He has also noticed intermittent joint pains, shortness of breath on exertion, and mild ankle swelling. He is concerned that he hasn’t been able to shake off this illness and wonders if he needs stronger antibiotics.

PATIENT RECORD SUMMARY

Patient Details

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

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

Mitral valve prolapse with a murmur (diagnosed in early adulthood)
Hypertension

Social History

Occupation: Accountant
Non-smoker, drinks alcohol socially
No history of intravenous drug use

Family History

No family history of endocarditis
Father had ischaemic heart disease

Vaccination and Preventative Activities

Up to date with routine vaccinations

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’ve been feeling really unwell for the past few weeks—fever, chills, and just exhausted all the time. It’s not getting better.”

General Information

(Can be shared freely if asked open-ended questions like “Tell me more about that.”)

You started feeling unwell about three weeks ago. At first, you thought it was just a cold or flu, but it hasn’t improved.
You have been experiencing low-grade fevers on and off, especially in the afternoons and evenings.
You feel exhausted all the time, even after a full night’s sleep.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You have lost about 4 kg in the past month without trying.
You feel achy all over, with some mild joint pains, particularly in your wrists, elbows, and knees.
You wake up drenched in sweat some nights and have to change your clothes.
You had a tooth removed about four weeks ago—the gum healed fine, but you didn’t take antibiotics before or after the procedure.

Cardiac Symptoms

You have a heart murmur, which you’ve known about for years due to mitral valve prolapse.
You haven’t had chest pain, but you’ve been feeling more breathless than usual, especially when walking up stairs.
You’ve noticed mild swelling in your ankles, but you thought it was from sitting at your desk all day.

Other Symptoms

No cough or runny nose.
No abdominal pain or nausea.
No recent travel.
You don’t use intravenous drugs and haven’t had any infections recently.
You haven’t noticed any rashes, but your palms look slightly different (Janeway lesions if the candidate asks).
You haven’t had any major headaches or neurological symptoms, but you’ve felt light-headed at times.

Concerns and Emotional State

You are frustrated that you’ve been sick for weeks with no improvement.
You are starting to worry that something serious is going on, especially since you’re losing weight.
You feel anxious because you’ve heard that heart infections can be dangerous.
You don’t want to go to hospital unless absolutely necessary because you have work and family responsibilities.
You feel concerned that this could be something permanent or serious, like heart valve damage.

Concerns and Questions for the Candidate

(Ask these naturally during the consultation, especially when discussing diagnosis or management.)

“Could this just be a virus, or do I need antibiotics?”
“Is my heart murmur getting worse? Could this be related?”
“I feel so exhausted—should I be worried this is something serious?”
“I’ve read about endocarditis before—is that what you’re thinking?”
“Do I really need to go to hospital? Can’t I just take some antibiotics at home?”
“How serious is this? What’s the worst-case scenario?”
“If this is an infection, could it have spread to other parts of my body?”

Role-Playing Emotional Cues

(Act these out realistically to simulate a real patient encounter.)

Concern: Furrow your brow and sigh when describing your ongoing symptoms.
Frustration: Shake your head or cross your arms when explaining how long this has been going on.
Fear: Look anxious and hesitate when asking about how serious this could be.
Reluctance: Sigh or look sceptical when the doctor suggests hospital admission.
Relief (if reassured well): Sit up straighter, nod, and engage more in the conversation.

What You Are Expecting From the Doctor (Candidate)

To take your symptoms seriously—you’ve been unwell for weeks and want real answers.
To explain why this could be more than a simple infection and why further tests are needed.
To clarify the link between your heart murmur and infection risk.
To be clear about the next steps, especially whether you need to go to hospital.
To address your fears about long-term complications, such as heart failure or valve damage.
To provide reassurance, but also be honest about the potential seriousness of the condition.

Potential Curveballs

(Optional, if the Candidate Handles the Basics Well)

“I don’t have time for a hospital admission. Can’t I just take oral antibiotics?”
“Do I need to tell my family about this, or can I wait until I have more information?”
“What if I refuse to go to hospital? Could I just monitor things for a few more days?”
“Could this be cancer? I’ve heard unexplained weight loss can be a bad sign.”
“If this is an infection in my heart, does that mean I might need surgery?”

End of Consultation

(If the candidate provides a clear plan and reassurance, respond positively.)

“Okay, I understand. I wasn’t expecting to need hospital care, but I trust your judgement. I just want to feel better and make sure my heart is okay.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, exploring the patient’s symptoms, risk factors, and concerns.

The competent candidate should:

Elicit key symptoms:
- Fever, night sweats, fatigue, weight loss.
- Joint pain, breathlessness, ankle swelling, neurological changes.
Explore risk factors for infective endocarditis (IE):
- Past history of mitral valve prolapse and murmur.
- Recent dental procedure without prophylactic antibiotics.
- Presence of predisposing conditions (e.g., congenital heart disease, prosthetic valves, immunosuppression).
Assess complications:
- Neurological symptoms (stroke, embolic events).
- Skin changes (Janeway lesions, Osler nodes).
- Cardiac symptoms (heart failure, new murmur).
Address patient’s concerns:
- Fear of serious illness and hospitalisation.
- Understanding of IE and its implications.

Task 2: Identify red flags for severe illness and complications such as heart failure, embolic events, or sepsis.

The competent candidate should:

Recognise signs of worsening infection:
- Persistent fever, rigors, malaise.
- Weight loss, fatigue, ongoing night sweats.
Assess for heart failure:
- Shortness of breath, orthopnoea, ankle swelling.
- New or worsening heart murmur.
Identify embolic complications:
- Neurological signs (sudden weakness, confusion, vision loss – possible stroke).
- Peripheral emboli (splinter haemorrhages, Janeway lesions, painful Osler nodes).
Screen for sepsis:
- Hypotension, tachycardia, confusion.
- Reduced urine output, generalised deterioration.

Task 3: Develop a structured management plan, including investigations, urgent referral, and empirical treatment.

The competent candidate should:

Urgent hospital referral for:
- Echocardiography (transthoracic or transoesophageal) to confirm diagnosis.
- Blood cultures (before antibiotics, 3 sets from different sites).
- Baseline blood tests: FBC, CRP, ESR, UEC, LFTs.
Empirical antibiotic therapy (as per local guidelines):
- IV benzylpenicillin + gentamicin (native valve) or
- Vancomycin + gentamicin (prosthetic valve or MRSA risk).
Specialist involvement:
- Cardiology for valve assessment.
- Infectious diseases for prolonged IV antibiotics.
Discuss need for prolonged antibiotic therapy (4-6 weeks), monitoring for complications, and follow-up with echocardiography.

Task 4: Address the patient’s concerns regarding their symptoms, potential diagnosis, and hospital admission.

The competent candidate should:

Acknowledge the patient’s distress and provide clear, empathetic communication.
Explain the seriousness of infective endocarditis:
- Can cause heart failure, stroke, or severe infection if untreated.
- Hospital admission is essential for IV antibiotics and monitoring.
Reassure that early treatment improves outcomes and that specialists will be involved.
Address concerns about hospitalisation:
- Work, family responsibilities, and length of stay (likely 4-6 weeks IV therapy).
Discuss long-term preventive measures:
- Good dental hygiene, antibiotic prophylaxis before procedures, and regular cardiac follow-up.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, covering symptoms, risk factors, and complications.
Identification of red flags, including heart failure, embolic events, and sepsis.
Urgent referral and evidence-based management, ensuring early antibiotics and specialist input.
Empathetic patient-centred approach, addressing concerns about severity and hospitalisation.
Preventive strategies, including dental hygiene and antibiotic prophylaxis for future procedures.

PITFALLS

Failing to recognise infective endocarditis, leading to delayed referral and increased mortality risk.
Not performing urgent blood cultures before antibiotics, reducing diagnostic accuracy.
Missing red flags for complications, such as embolic events or heart failure.
Reassuring the patient incorrectly, suggesting oral antibiotics or outpatient management.
Not addressing preventive strategies, increasing future risk of recurrence.

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.
1.5 Provides clear and sensitive explanations of potential diagnoses and required investigations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to assess risk factors for infective endocarditis.
2.2 Identifies red flags for severe infection and cardiac complications.
2.3 Orders and interprets appropriate investigations for suspected infective endocarditis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of infective endocarditis and considers it in the differential diagnosis.
3.3 Differentiates between infective endocarditis and alternative causes of fever and systemic illness.

4. Clinical Management and Therapeutic Reasoning

4.2 Initiates urgent referral for hospitalisation and specialist input.
4.4 Ensures appropriate empirical antibiotic therapy is commenced.

5. Preventive and Population Health

5.2 Provides education on risk factors, including dental hygiene and intravenous drug use.

6. Professionalism

6.2 Demonstrates sensitivity in discussing a potentially life-threatening illness.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures timely referral to appropriate healthcare services.

9. Managing Uncertainty

9.1 Addresses patient concerns about the seriousness of their condition and potential complications.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates urgent management for suspected infective endocarditis.

Competency at Fellowship Level

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