Current expanded assessment design
Three cases. Nine clinical decisions.
Each module has three baseline decisions, three formative case exercises and three parallel post decisions. The nine 60-day items are reserved for follow-up. No extra essay is required.
Renee · Breathlessness With a Preserved EF
Renee’s full story
Renee can no longer finish her usual walk. She recalls being told that EF 63% was normal. Her symptoms remain stable. Which response best keeps the evaluation on track?
- Reassure her that normal EF rules out a cardiac explanation.
- Connect her functional decline to the full examination, echo and differential.
- Diagnose HFpEF because obesity and hypertension are present.
Answer and reasoning
Connect her functional decline to the full examination, echo and differential.
A preserved pumping percentage does not explain the symptom or establish HFpEF. The next decision depends on the complete clinical picture.
Baseline E1-recognition-pre → practice E1-practice-1 → post E1-recognition-post. Independent approval and pilot pending.
The next result
A complete resting evaluation gives Renee an HFA-PEFF score of 3. Important alternatives have been assessed, but exertional limitation persists. What is the next diagnostic aim?
- Confirm HFpEF from this score alone.
- Stop testing because resting results are not diagnostic.
- Resolve the intermediate probability with appropriate specialist functional assessment.
Answer and reasoning
Resolve the intermediate probability with appropriate specialist functional assessment.
The score is intermediate. Select functional testing that can resolve the uncertainty; feasibility and specialist expertise matter. Inconclusive noninvasive assessment may lead to selected invasive exercise testing.
Baseline E1-confirmation-pre → practice E1-practice-2 → post E1-confirmation-post. Independent approval and pilot pending.
A change in urgency
Before the planned outpatient assessment, Renee develops chest pressure and severe breathlessness at rest. What changes?
- The new symptoms require urgent assessment.
- The earlier EF makes the new symptoms reassuring.
- Wait for the scheduled functional test.
Answer and reasoning
The new symptoms require urgent assessment.
The new presentation takes priority over a stable outpatient pathway. Prior reassuring measurements must not delay urgent evaluation.
Baseline E1-alternatives-pre → practice E1-practice-3 → post E1-alternatives-post. Independent approval and pilot pending.
Angela · What Changes After HFpEF Is Confirmed?
Angela’s treatment conversation
Angela has confirmed HFpEF and asks why a medicine often associated with diabetes is being considered when her A1c is 5.8%. Which explanation is appropriate?
- HF benefit depends on lowering her glucose.
- Discuss HF trial evidence and individual eligibility even without diabetes.
- Use an SGLT2 inhibitor only after diabetes develops.
Answer and reasoning
Discuss HF trial evidence and individual eligibility even without diabetes.
The HF evidence is not restricted to diabetes. Review product-specific eligibility, renal function, volume, precautions and access, and explain the relevant HF outcomes.
Baseline E2-sglt2-pre → practice E2-practice-1 → post E2-sglt2-post. Independent approval and pilot pending.
An evidence claim to challenge
Angela reads that a positive composite outcome in SUMMIT means tirzepatide was proven to prevent cardiovascular death in HFpEF. How should you respond?
- The composite proves equal benefit for each component.
- Comparing separate trials proves which obesity drug is best.
- Explain the composite benefit and its components without asserting a proven cardiovascular-mortality benefit.
Answer and reasoning
Explain the composite benefit and its components without asserting a proven cardiovascular-mortality benefit.
Separate symptoms, function, weight and clinical-event outcomes. The positive composite does not establish benefit for every component, and separate trials are not a head-to-head comparison.
Baseline E2-endpoints-pre → practice E2-practice-2 → post E2-endpoints-post. Independent approval and pilot pending.
The monitoring detail
For an otherwise eligible finerenone HF candidate with EF 58%, baseline eGFR 42 and potassium 4.7, which plan matches the current HF label?
- Start 10 mg daily and check potassium/eGFR at four weeks; use the full HF table for adjustment.
- Start at the 40 mg target without checking renal category.
- Start 20 mg and omit monitoring unless symptoms develop.
Answer and reasoning
Start 10 mg daily and check potassium/eGFR at four weeks; use the full HF table for adjustment.
For this baseline renal category the start is 10 mg and the HF target is 20 mg when eligible. Review interactions and contraindications and reassess potassium/eGFR four weeks after initiation or a dose change; earlier review may be needed clinically.
Baseline E2-finerenone-pre → practice E2-practice-3 → post E2-finerenone-post. Independent approval and pilot pending.
Teresa · Keeping the Plan Working
Teresa calls during an illness
After starting an SGLT2 inhibitor, Teresa has vomiting, poor intake, abdominal pain and breathlessness. Her glucose is 146 mg/dL. Which response is safest?
- Wait because the glucose is not markedly elevated.
- Hold the SGLT2 inhibitor and arrange urgent assessment for possible ketoacidosis and other acute causes.
- Wait for her routine four-week blood test.
Answer and reasoning
Hold the SGLT2 inhibitor and arrange urgent assessment for possible ketoacidosis and other acute causes.
Ketoacidosis may occur without marked hyperglycemia. Concerning symptoms and poor intake require urgent assessment; a routine monitoring schedule is not the appropriate pathway.
Baseline E3-acute_safety-pre → practice E3-practice-1 → post E3-acute_safety-post. Independent approval and pilot pending.
A separate, stable visit
At a later stable visit, a baseline potassium result of 5.3 returns before Teresa has taken her first finerenone dose. What should happen?
- Give the first dose and recheck at four weeks.
- Ignore potassium because the eGFR is eligible.
- Do not initiate; review the result, contributing factors and complete eligibility.
Answer and reasoning
Do not initiate; review the result, contributing factors and complete eligibility.
The current label says not to initiate when baseline potassium is above 5.0 mEq/L. This is an initiation decision, not a maintenance-dose adjustment.
Baseline E3-lab_action-pre → practice E3-practice-2 → post E3-lab_action-post. Independent approval and pilot pending.
The missing result
After a subsequent eligible start, the ordered potassium/eGFR result is absent. Teresa could not arrange transportation. What closes the gap?
- Assign a reviewer and backup, resolve access, obtain/retrieve the test and communicate the reviewed plan.
- Place another order and mark the task complete.
- Assume no abnormality because no result was received.
Answer and reasoning
Assign a reviewer and backup, resolve access, obtain/retrieve the test and communicate the reviewed plan.
A named owner must track the test through interpretation and communication. Resolve the practical barrier and retain responsibility until the receiving clinician or team accepts it.
Baseline E3-ownership-pre → practice E3-practice-3 → post E3-ownership-post. Independent approval and pilot pending.