CCE-CE-041.1 - GP Exams

CASE INFORMATION

Case ID: CCE-COPD-002
Case Name: John Patterson
Age: 68
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R95 – Chronic obstructive pulmonary disease (COPD)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear and structured explanations about diagnosis and management
2. Clinical Information Gathering and Interpretation	2.1 Elicits a relevant history, including smoking and occupational exposures 2.2 Assesses severity of COPD symptoms using validated tools (e.g., MRC dyspnoea scale)
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies exacerbation triggers and differential diagnoses 3.2 Recognises red flags indicating hospitalisation
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a COPD management plan, including inhaler therapy, pulmonary rehabilitation, and smoking cessation 4.2 Prescribes appropriate medications (e.g., bronchodilators, corticosteroids) and assesses inhaler technique
5. Preventive and Population Health	5.1 Provides vaccination advice (influenza, pneumococcal) 5.2 Discusses smoking cessation strategies
6. Professionalism	6.1 Demonstrates empathy and patient-centred care
7. General Practice Systems and Regulatory Requirements	7.1 Refers to appropriate support services (e.g., My Aged Care, pulmonary rehab)
8. Procedural Skills	8.1 Demonstrates correct use of inhaler devices
9. Managing Uncertainty	9.1 Recognises when to escalate care (e.g., signs of impending respiratory failure)
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages COPD exacerbations appropriately

CASE FEATURES

Requires optimisation of long-term management, including inhaler use and pulmonary rehab
Long-standing COPD with increasing breathlessness
History of smoking, previous exacerbations, and hospitalisation
Currently experiencing worsening symptoms
Concern about need for hospital admission

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, including smoking history, symptom control, and exacerbation triggers.
Identify the key issues in the management of this patient’s COPD, including pharmacological and non-pharmacological options.
Provide education on COPD management, including inhaler technique, vaccinations, and pulmonary rehabilitation.
Discuss a management plan, including escalation of care if needed.

SCENARIO

John Patterson, a 68-year-old retired construction worker, presents to your general practice complaining of worsening breathlessness over the past two weeks. He reports increasing sputum production, occasional wheezing, and fatigue. He has had two previous COPD exacerbations requiring hospitalisation in the last year.

John has a 40-pack-year smoking history and quit smoking five years ago. He has been using his prescribed inhalers but admits he is unsure if he is using them correctly. He has not attended pulmonary rehabilitation.

His main concern is whether he will need to go to the hospital. He also wants to know if there are any treatments to improve his breathlessness.

PATIENT RECORD SUMMARY

Patient Details

Name: John Patterson
Age: 68
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Tiotropium 18 mcg inhaled daily
Salbutamol 100 mcg inhaled PRN
Fluticasone/Salmeterol 250/25 mcg inhaled BD
Amlodipine 5 mg daily

Past History

Chronic obstructive pulmonary disease (diagnosed 10 years ago)
Hypertension
Ischaemic heart disease (stent inserted 5 years ago)

Social History

Retired construction worker, lives with wife
Quit smoking 5 years ago (40-pack-year history)
Limited physical activity due to breathlessness

Family History

Father had COPD and passed away from respiratory failure

Smoking

Former smoker, quit 5 years ago

Alcohol

Drinks beer occasionally (2-3 per week)

Vaccination and Preventative Activities

No previous pulmonary rehabilitation
No recent influenza or pneumococcal vaccine

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 feel like my breathing is getting worse, and I’m worried I might have to go to hospital again.”

General Information

John Patterson, a 68-year-old retired construction worker, has been feeling increasingly short of breath over the past two weeks. He notices that even simple tasks, like walking to the mailbox or getting up from a chair, make him breathless. He wakes up at night feeling like he can’t catch his breath and has been using his reliever inhaler (salbutamol) more often. He produces more phlegm than usual, which is yellowish in colour, but has not had a fever. His wife has been nagging him to see the doctor because she thinks he is getting worse.

John has had COPD for 10 years and was diagnosed after experiencing frequent cough and breathlessness. He quit smoking five years ago after his second hospitalisation for a COPD exacerbation. He is frustrated that despite quitting smoking, his condition still seems to be worsening.

He takes his prescribed inhalers but isn’t sure if he is using them correctly. He uses his preventer inhaler most of the time but admits to occasionally forgetting. He has never attended pulmonary rehabilitation because he didn’t think it would be helpful. He hasn’t had his flu or pneumococcal vaccine this year because he wasn’t sure if they were necessary.

Specific Information (To be revealed only when asked)

Symptoms and Exacerbation History

Breathlessness has worsened gradually over two weeks.
He has been waking up at night feeling short of breath.
He has more phlegm than usual, which is yellowish, but no blood.
No fever, but feels fatigued and weak.
He has had two hospital admissions in the past year for COPD exacerbations.

Medication and Inhaler Use

Uses salbutamol (Ventolin) frequently but isn’t sure if it helps as much as before.
Takes his tiotropium (Spiriva) most days but occasionally forgets.
Not sure if he is using his inhalers correctly.
Has never been formally taught how to use them.

Lifestyle and Preventative Care

Quit smoking five years ago but smoked for 40 years before that.
His wife helps with daily tasks because he gets tired easily.
Has never been to pulmonary rehabilitation; doesn’t really know what it involves.
No recent flu or pneumococcal vaccine.

Emotional Cues

Anxiety about worsening breathlessness: “I don’t want to end up in hospital again.”
Frustration about COPD despite quitting smoking: “I thought quitting would stop this from getting worse.”
Worry about long-term health: “My father had COPD, and he ended up on oxygen all the time. I don’t want to be like that.”
Embarrassment about not knowing how to use inhalers properly: “I feel a bit silly asking, but am I using these inhalers right?”

Questions for the Candidate

“Is my COPD getting worse? Am I going to end up in hospital again?”
“Do I need to change my medications? This inhaler doesn’t seem to work like it used to.”
“What can I do to stop this from happening again?”
“Is there anything I can do to breathe better?”
“I’ve heard about pulmonary rehab. Is that something I should do?”
“Will I need oxygen at home? I see people walking around with oxygen tanks, and I don’t want to end up like that.”

Personality and Communication Style

Generally polite but slightly impatient, especially when discussing hospitalisation.
A bit sceptical about new treatments but open to explanations.
Wants clear, straightforward answers.
More likely to engage when the doctor acknowledges his concerns and provides practical solutions.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including smoking history, symptom control, and exacerbation triggers.

The competent candidate should:

Elicit symptom progression – onset, duration, and severity of breathlessness, sputum production, and cough.
Clarify exacerbation triggers – recent infections, weather changes, medication adherence, and environmental exposures.
Assess smoking history – past and current smoking status, quit attempts, and impact on COPD.
Review inhaler use and adherence – determine if the patient understands how to use inhalers correctly.
Screen for systemic symptoms – fever, weight loss, or signs of respiratory failure (cyanosis, confusion).
Explore functional impact – ability to perform daily activities and quality of life.

Task 2: Identify the key issues in the management of this patient’s COPD, including pharmacological and non-pharmacological options.

The competent candidate should:

Recognise the severity of COPD – frequent exacerbations, increased inhaler use, and hospital admissions.
Optimise pharmacological treatment – review inhaler therapy, consider long-acting bronchodilators, or oral corticosteroids if indicated.
Address inhaler technique and adherence – provide education and demonstrate correct usage.
Recommend pulmonary rehabilitation – explain benefits and encourage participation.
Discuss smoking cessation support – reinforce quitting benefits and offer NRT or pharmacotherapy if necessary.
Ensure vaccination status – advise influenza and pneumococcal vaccines.
Consider referral for specialist review – if frequent exacerbations or severe symptoms.

Task 3: Provide education on COPD management, including inhaler technique, vaccinations, and pulmonary rehabilitation.

The competent candidate should:

Explain COPD pathophysiology in simple terms – irreversible airflow limitation and importance of management.
Demonstrate proper inhaler technique – check patient’s technique and correct errors.
Educate on exacerbation management – early signs, when to use reliever, and when to seek medical attention.
Promote pulmonary rehabilitation – benefits in improving breathlessness and reducing hospital admissions.
Encourage regular vaccinations – flu and pneumococcal vaccines reduce infection risk.

Task 4: Discuss a management plan, including escalation of care if needed.

The competent candidate should:

Provide a structured action plan – when to use medications, when to increase reliever use, and when to seek medical help.
Arrange follow-up – review within 1-2 weeks to assess response to treatment.
Consider oxygen therapy if indicated – assess for long-term oxygen needs.
Discuss advance care planning – if appropriate, address patient’s preferences for future care.

SUMMARY OF A COMPETENT ANSWER

Elicits a thorough history of symptom progression, exacerbation triggers, and impact on daily life.
Identifies red flags that indicate severe COPD or impending respiratory failure.
Optimises pharmacological therapy, ensuring correct inhaler use and adherence.
Encourages pulmonary rehabilitation and explains its role in COPD management.
Emphasises smoking cessation and preventative care, including vaccinations.
Provides a clear action plan and follow-up to prevent future exacerbations.

PITFALLS

Failure to assess inhaler technique – missing a common cause of poor symptom control.
Not recognising red flags – such as increasing breathlessness, hypoxia, or systemic infection.
Overlooking non-pharmacological management – like pulmonary rehabilitation or smoking cessation.
Providing a generic management plan – without tailoring to patient’s specific needs and preferences.
Ignoring patient concerns and quality of life impact – leading to poor adherence to management.

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.
1.3 Provides clear and structured explanations about diagnosis and management.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a relevant history, including smoking and occupational exposures.
2.2 Assesses severity of COPD symptoms using validated tools (e.g., MRC dyspnoea scale).

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies exacerbation triggers and differential diagnoses.
3.2 Recognises red flags indicating hospitalisation.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a COPD management plan, including inhaler therapy, pulmonary rehabilitation, and smoking cessation.
4.2 Prescribes appropriate medications (e.g., bronchodilators, corticosteroids) and assesses inhaler technique.

5. Preventive and Population Health

5.1 Provides vaccination advice (influenza, pneumococcal).
5.2 Discusses smoking cessation strategies.

6. Professionalism

6.1 Demonstrates empathy and patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.1 Refers to appropriate support services (e.g., My Aged Care, pulmonary rehab).

8. Procedural Skills

8.1 Demonstrates correct use of inhaler devices.

9. Managing Uncertainty

9.1 Recognises when to escalate care (e.g., signs of impending respiratory failure).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages COPD exacerbations appropriately.

Competency at Fellowship Level

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