ℹ️ This is the case information for the doctor.
Name
John Johnson
Age
82 years
Address
1 Duckworth Grove
Social history
Retired mechanical engineer
Past history
Investigation results
Medication
Booking note
Follow up appointment for results.
ℹ️ This is the information for the person role playing the patient.
Name
John Johnson
Age
82 years
Address
1 Duckworth Grove
Social history
Retired mechanical engineer
Past history
Medication
"I've come back for the results of the heart test I had done a while ago, doctor. I've been feeling more tired than usual lately."
Questions on learning of your diagnosis:
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety:
Data gathering was incomplete, lacking structure and focus:
Makes effective use of existing information and considers the wider context:
Fails to use the information provided or understand the wider context:
The presence or absence of relevant red flags was established:
Fails to assess key information necessary to determine risk:
Information gathered placed the problem in its psychosocial context:
The social and psychological impact of the problem was not adequately determined:
A working diagnosis was reached using a structured, evidence-based approach:
The evidence collected was inadequate to support the conclusions reached:
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making:
Choice of diagnosis and/or investigations does not reflect disease likelihood:
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate:
Fails to provide appropriate and/or safe management choices:
Continuity of care is prioritised:
Ongoing care is uncoordinated:
Empowers self-care and independence:
Management fails to foster self-care and patient involvement:
Prescribes safely considering local and national guidance:
Unsafe prescribing ignoring best practice:
Assesses risk:
Poor understanding of risk:
Manages multiple health problems concurrently:
Focuses on individual health problems without considering interactions between them:
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Communicates in a person-centred way:
Communication is doctor centred and lacks empathy:
Demonstrates flexibility of communication adapting to the patient and scenario:
Consults rigidly, providing generic explanations and management plans:
Checks the patient’s understanding of the consultation including any agreed plans:
Does not seek to confirm understanding:
Demonstrates an empathic approach, and a willingness to help and care for the patient:
Lacks empathy and fails to recognise emotional cues:
Treats patients fairly and with respect:
Decisions fail to prioritise the patient’s rights and interests:
Takes ownership of decisions utilising the wider team:
Does not take ownership or utilise the wider team effectively:
ℹ️ Insights from the examiner
Case at a glance
John has had recent tests, including an ECG showing atrial fibrillation (AF). He may be attending to understand the result and what it means for him.
He has symptoms such as tiredness, which may be affecting activities he values, particularly gardening. He is curious rather than highly anxious, but he has concerns about treatment — especially the possibility of frequent blood-test monitoring if anticoagulation is needed.
The consultation should explain AF clearly, assess symptoms and impact, discuss stroke prevention and bleeding risk, and tailor management to John’s goals and practical concerns.
GP trainee performance focus
A strong GP trainee should demonstrate the ability to:
What this case is testing
Patient priorities and concerns
John may want to understand:
Central challenge
The central challenge is to explain AF and stroke-prevention treatment clearly without overwhelming John, while addressing his practical concern about monitoring.
The trainee should avoid:
Must-not-miss issue or diagnosis
The key must-not-miss issue is that AF can increase stroke risk, and John may need anticoagulation depending on risk assessment.
The consultation also needs to consider symptoms such as tiredness and whether rate control or further management may improve his quality of life.
Red flags or high-risk features
Assess:
Common GP trainee pitfalls
What good looks like
A good consultation is clear, calm and personalised. The trainee explains the ECG result simply, explores John’s symptoms and goals, explains stroke prevention options, and offers a treatment plan that reduces monitoring burden where possible.
“The heart test you had — your ECG — shows your heart is beating in an irregular way called atrial fibrillation. This is common, especially as people get older. It can make people feel tired, and it can also increase the risk of stroke, so we should talk through how we can reduce that risk.”
Learner checkpoint
Have I explained AF and anticoagulation in a way that connects to John’s life, concerns and goals?
Start with an open question
Use an opening that shows preparation but avoids assuming John’s agenda.
“I can see you have had some tests done — was that what you came about today?”
Another option:
“We haven’t met before and I can see you have had some tests recently. Can you tell me more about why you had them?”
This invites John to tell his story and helps uncover symptoms, ideas, concerns and expectations.
Time-efficient data gathering
Use John’s story to guide focused questions. Clarify:
High-yield questions
Understanding and agenda
Symptoms and impact
Treatment concerns
Practical context
Functional, psychosocial or contextual assessment
Explore how AF and tiredness affect John’s wellbeing:
This helps tailor urgency, treatment and follow-up.
Explore ideas, concerns and expectations
John may not be very anxious, but he is curious and may have assumptions about warfarin.
Useful prompts:
“It’s great you’re curious — many people don’t know much about AF.”
“A lot of people have heard of warfarin, but there are now newer medications that might suit you better and don’t need frequent blood testing.”
If travel is a concern:
“I appreciate that getting out for appointments can be a challenge for some people.”
Recognise and respond to cues
Important cues may include:
Respond by validating and linking management to John’s goals.
“I can see you want to get back to gardening, or is there something else you hope for?”
Useful consultation phrases
“Your ECG shows atrial fibrillation, which is when your heart beats irregularly.”
“This can make you feel tired and, if untreated, increases the risk of stroke.”
“To reduce that risk, we use medicines to thin the blood.”
“The older type, warfarin, needs regular blood tests, but newer ones often don’t need that kind of frequent monitoring.”
“It can reduce your energy levels, and perhaps that is why you have not been able to enjoy your garden as much. The good news is there is treatment that can help.”
Consultation flow and signposting
Summarising and checking understanding
Summarise before moving into management:
“So, the ECG shows atrial fibrillation. You’ve noticed tiredness that is affecting your gardening, and one of your concerns is whether treatment would mean lots of blood tests. Let’s go through the options and what they would mean for you.”
Check:
Data gathering self-check
Before agreeing management, the trainee should know:
Assessment domain mapping
Data gathering
Clinical management
Relating to others
Prioritised differential diagnosis or clinical reasoning
This is primarily a management and explanation case. The key clinical reasoning task is to:
Clinical reasoning script
“Given your age and the ECG result, AF can increase your chance of stroke. We usually use a checklist — a risk score — to work out whether a blood thinner is recommended and whether it is safe for you. We can go through that together.”
Red flags and risk assessment
Risk assessment should include:
Decision points
Key decisions include:
Management priority
The management priority is to reduce John’s stroke risk while addressing symptoms and practical treatment burden.
A strong plan should also support his goal of returning to activities he enjoys.
“Let’s aim to reduce your stroke risk and help you feel more energetic for activities you enjoy.”
Management options
1. DOAC anticoagulation
Discuss starting a DOAC such as:
DOACs are preferred where appropriate because they require minimal monitoring compared with warfarin.
Explain:
“That’s the case with warfarin, but with newer anticoagulants like apixaban or rivaroxaban, you won’t need to come in very often at all.”
Also explain:
“We’ll just check bloods every year, unless there’s a problem, which people usually find much easier.”
2. Warfarin
Discuss warfarin as a traditional option.
Explain that it:
3. Rate control medication
Discuss medication to steady the heart rate, where appropriate.
Explain that this may help symptoms such as tiredness if AF is contributing.
4. Rhythm control
Discuss rhythm control in some cases, particularly if symptoms persist.
This may include medicines or procedures to restore normal rhythm, depending on ongoing assessment.
5. Lifestyle advice
Discuss:
Keep advice practical and linked to John’s activities.
6. Blood pressure monitoring
Arrange regular blood pressure checks and adjust medication as needed.
7. Education materials
Offer written or online information about AF, such as:
8. Social prescribing or transport help
If monitoring or appointments are a barrier, consider:
9. Regular follow-up and continuity
Arrange follow-up, ideally with the same doctor or nurse practitioner where possible.
10. Bleeding risk assessment
Discuss:
Personalised plan
A plan tailored to John might include:
Example phrase:
“Considering your concerns about travel for blood tests, a newer anticoagulant would avoid the need for frequent visits. Is that something you’d find helpful?”
Another personalised summary:
“As you’re keen to get back to gardening, and we’ve agreed we should try to reduce your chance of a stroke, starting a blood thinner and another medicine to keep your heart rate from racing might be the best option from those we’ve discussed. We would monitor how you feel and keep an eye out for side effects.”
Shared decision-making
Use shared decision-making by asking:
“Can I check — does it make sense why we’re recommending this treatment, and how it might help you?”
“What questions do you have about these options?”
“How do you feel about the idea of taking a medication to thin the blood and help protect against stroke?”
John’s values should shape the plan, especially:
Safety-netting
Keep safety-netting focused on treatment monitoring and agreed review.
Advise John to seek review if:
Ensure he knows how follow-up will happen and who to contact.
Documentation points
Document:
Common unsafe management plans
Avoid:
Follow-up and coordination with other professionals
Arrange follow-up to review:
Consider continuity with the same doctor or nurse practitioner where possible.
Learner checkpoint
Have I offered John a stroke-prevention plan that is clinically appropriate and practical for his life?
Relevant guidance areas
NICE guidance
BNF references
RCGP and SCA resources
Patient information websites
Relevant research or educational references
Key principles to remember
Transferable learning for future cases
When discussing new test results:
Supervisor or examiner lens
A supervisor or examiner is likely to look for:
Final learner takeaway
New AF consultations work best when you explain the result simply, connect treatment to the patient’s goals, and make stroke prevention practical as well as evidence-based.
