Sample · RACP
Ischaemic cardiomyopathy with AF, CKD and diabetes: a carer who is struggling
Long case · Cardiology · 17 marks. Decide what you would do, then compare with the marking guide and model performance. In the app you run it against the clock, with a colleague or an AI role-player, and it comes back marked.
Mr Kevin O'Rourke is a 71-year-old retired electrician who lives in a regional town. He has been admitted for the third time this year with breathlessness and is now euvolaemic and awaiting discharge. His medication list is attached to the bedside chart. You have 60 minutes with Mr O'Rourke to take a history and examine him. You will then have 10 minutes to prepare, followed by 25 minutes to present the case to the examiners and discuss his management. No notes or investigation results are provided; ask the examiners for any results you need during the discussion.
- Present a prioritised summary of Mr O'Rourke's history and examination findings.
- Identify and rank his active problems, including those that matter most to him.
- Discuss the investigations you would request and how they would change management.
- Outline a management plan for the next three to six months, including his social circumstances.
Show the marking guide and model performance
- History accurate and complete: NYHA class, admission pattern, and the reversible precipitants (over-the-counter NSAID, dietary sodium, missed doses, no daily weights) (2)
- Complete medicine reconciliation, identifying the OTC ibuprofen, aspirin continued with apixaban without indication, and metformin above the maximum for eGFR 30–44 (1 g per day) (2)
- Examination findings accurate: AF, postural drop, JVP and abdominojugular reflux, displaced apex, functional MR murmur, crackles, oedema, tophus, diabetic neuropathy with absent monofilament sensation (2)
- Opening one-line synthesis and a ranked problem list that puts recurrent decompensation and its precipitants first, and does not undervalue the carer situation (2)
- Targeted investigations with a stated purpose (echo, ECG with QRS width, potassium/renal function trend, iron studies with TSAT), avoiding scattergun tests (1)
- Correctly manages hyperkalaemia without abandoning prognostic therapy: stop NSAID, dietary potassium review, potassium binder, recheck in about a week; spironolactone halved above 5.5 and held only at 6.0 mmol/L or more (1)
- Identifies iron deficiency in heart failure (ferritin <100 µg/L, or 100–299 with TSAT <20%) and recommends IV iron (e.g. ferric carboxymaltose) (1)
- Discusses cardiac resynchronisation therapy with defibrillator (LVEF ≤35%, LBBB with QRS ≥150 ms, symptomatic on optimal therapy) and the AF caveat (needs near-100% biventricular pacing, may need atrioventricular node ablation) (1)
- Correct apixaban dosing reasoning and stops aspirin (stable coronary disease >12 months on anticoagulant) (1)
- Impact of illness: carer burden, wife's undiagnosed cognitive decline, respite and My Aged Care, daughter involvement, mood screening (2)
- Long-term view: cardiac rehabilitation/heart failure nurse follow-up, daily weights and action plan, gout prophylaxis plan without NSAIDs, driving advice after device implantation, prognosis and advance care planning (2)
"Mr O'Rourke is a 71-year-old retired electrician and the sole carer for his wife, who has undiagnosed cognitive decline. He has ischaemic cardiomyopathy with an ejection fraction I expect to be severely reduced, now NYHA class III, with three admissions this year driven by reversible factors: over-the-counter ibuprofen for gout, a high-sodium diet since caring took over his time, and missed evening doses. His main goal is to stay home with his wife.
His comorbidities are persistent AF on apixaban, CKD with a rising creatinine, type 2 diabetes with peripheral neuropathy, and gout. On examination he is in AF at 86, with a postural drop to 96/58, JVP 4 centimetres with abdominojugular reflux, a displaced apex, a pansystolic murmur I think is functional mitral regurgitation, bibasal crackles and oedema to the mid-shins, so he is not yet at dry weight. He has an absent monofilament on the left foot and a first MTP tophus.
My problems in order are: first, recurrent decompensation with modifiable precipitants; second, hyperkalaemia that threatens his prognostic therapy; third, medication safety, because he is on aspirin with apixaban without a current indication and metformin at twice the maximum for an eGFR in the thirties; fourth, his wife's safety and his carer strain; and fifth, prognosis and planning.
I would ask for his echo, an ECG for QRS width, the potassium and creatinine trend, and iron studies with transferrin saturation."
On discussion: "With ferritin 85 he has iron deficiency and should have IV ferric carboxymaltose. I would stop the ibuprofen and aspirin, review dietary potassium, start a potassium binder and recheck in a week rather than stop the spironolactone. Metformin goes to 500 mg twice daily. With LBBB and QRS 156 on optimal therapy he meets CRT-D criteria, but in AF he needs near-complete biventricular pacing, so I would discuss AV node ablation with the electrophysiologist. Gout prophylaxis means titrating allopurinol with colchicine cover, not NSAIDs. Before discharge, the key thing is a plan for Maureen: a My Aged Care referral, emergency respite, a call to their daughter, and referral for cognitive assessment. He needs scales, a weight action plan, heart failure nurse follow-up, and an early conversation about what matters to him if he deteriorates."
Where candidates lose marks here
- Taking the chart medicine list at face value: examiners expect the candidate to have asked about over-the-counter medicines and found the ibuprofen.
- Reporting a third heart sound or a "normal JVP" that the examiners do not find when they re-examine.
- Stopping prognostic heart failure therapy for moderate hyperkalaemia instead of removing the cause and using a binder.
- Presenting the wife's cognitive decline as background colour rather than a problem that will determine whether he can safely go home.
- Listing every possible investigation (coronary angiography, cardiac MRI, sleep study) without saying how each would change management.
Original content written for Fellowship Ready, for exam preparation only, not clinical advice. Not affiliated with the Royal Australasian College of Physicians (RACP).