CASE INFORMATION

Case ID: CVD-002
Case Name: David Reynolds
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K74 – Cardiovascular Disease NOS

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Demonstrates active listening and empathy. 1.4 Explains diagnosis and management in a patient-centred manner.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including cardiovascular risk factors and symptoms. 2.2 Identifies red flags requiring further investigation.
3. Diagnosis, Decision-Making and Reasoning	3.1 Establishes a working diagnosis based on history and clinical reasoning. 3.2 Utilises cardiovascular risk assessment tools to stratify risk.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.5 Provides lifestyle and pharmacological recommendations. 4.7 Ensures patient-centred shared decision-making.
5. Preventive and Population Health	5.1 Provides guidance on cardiovascular risk reduction. 5.2 Advises on lifestyle modifications, including diet and exercise.
6. Professionalism	6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements	7.1 Documents history, investigations, and management plan appropriately.
9. Managing Uncertainty	9.3 Recognises the potential for undifferentiated presentations and discusses appropriate follow-up.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when referral for further investigation or specialist input is required.

CASE FEATURES

Need for shared decision-making and appropriate follow-up.
Middle-aged male with multiple cardiovascular risk factors.
Mild but persistent exertional chest discomfort, leading to diagnostic uncertainty.
Raised cardiovascular risk score, requiring discussion on primary and secondary prevention.
Patient is reluctant to take medications and is seeking reassurance.

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

David Reynolds, a 58-year-old truck driver, presents to your general practice with a three-month history of intermittent chest discomfort. He describes the sensation as a mild tightness across his chest that occurs after climbing stairs or carrying heavy loads, relieving with rest after a few minutes.

His observations today are:

BP: 148/92 mmHg
HR: 78 bpm, regular
BMI: 29 kg/m²
Lipid Profile (from 6 months ago):
- Total cholesterol: 6.2 mmol/L
- LDL: 4.1 mmol/L
- HDL: 1.0 mmol/L
- Triglycerides: 2.5 mmol/L

PATIENT RECORD SUMMARY

Patient Details

Name: David Reynolds
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No previous cardiovascular disease
No known diabetes or chronic conditions

Social History

Occupation: Truck driver
Smoker: 15 cigarettes/day for 35 years
Alcohol: 2-3 standard drinks per night

Family History

Father: Myocardial infarction at 62
Mother: Hypertension

Vaccination and Preventative Activities

Influenza vaccine – up to date

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 SCRIPTS

Opening Line

“Doctor, I keep getting this mild tightness in my chest when I do something physical. It’s not bad, but I just want to make sure it’s nothing serious.”

General Information

The chest tightness started about three months ago.
It happens only when doing something physical (e.g., climbing stairs, lifting heavy objects) and goes away within a few minutes when you rest.
The tightness is not severe, not sharp pain, and doesn’t spread to the arms, jaw, or back.
It’s not getting worse, but you’ve started noticing it more frequently over the last few weeks.

Specific Information

(Only Provide If Asked)

You haven’t had any episodes while resting, and you don’t wake up at night with chest pain.
You sometimes feel a bit breathless when walking uphill, but it settles quickly when you stop.
You have no dizziness, fainting, palpitations, nausea, or sweating.
You don’t think it’s heartburn because it’s not related to eating.

Lifestyle and Risk Factors

You have been smoking 15 cigarettes per day for 35 years and have tried to quit before, but it “never stuck.”
You drink alcohol most nights—about 2-3 standard drinks—mainly beer.
Your diet isn’t great. You eat a lot of processed foods and takeaway meals due to your work schedule.
You don’t eat many fruits or vegetables and often skip meals when you’re busy.
You don’t exercise much apart from work-related activity.
You don’t check your blood pressure or cholesterol regularly, but you recall a doctor once saying your cholesterol was “on the high side.”
You’ve never had a heart attack or stroke, but your father had a heart attack at 62.

Red Flags (None Present)

You haven’t lost weight unexpectedly.
No sudden, severe chest pain.
No pain at rest or while sleeping.
No blackouts or fainting.
No cough, fever, or signs of infection.

Psychological & Emotional State

You feel worried about your heart because of your father’s history.
You don’t want to be put on medication for life if it can be avoided.
You feel okay overall, apart from feeling tired sometimes, but you think that’s due to work.
You sometimes wake up feeling unrefreshed, but you don’t think it’s serious.
You’re not the type to go to the doctor often and usually only come when your wife insists.
You don’t like being told what to do, especially when it comes to health.

Concerns & Expectations

You want to know if this is a heart problem or something else.
You are not keen on taking medication and would rather try lifestyle changes first.
You want to know if you need a scan or heart tests.
You’re wondering if this is just a normal part of getting older.
You are scared of having a heart attack like your dad but don’t want to “overreact.”
You don’t want to make big changes to your lifestyle unless it’s absolutely necessary.

Possible Questions for the Candidate

“Do you think this could be a heart problem?”
“Do I really need to take medication? I don’t want to be on pills for the rest of my life.”
“Are there other ways I can lower my risk?”
“Will I need a stress test or something like that?”
“Could this just be a normal part of getting older?”
“If I change my diet, will that be enough?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains the Diagnosis Well:

“Okay, so you’re saying this could be related to my heart, but it’s not a heart attack yet?”
“That makes sense, but how do we know for sure?”

If the Candidate Recommends Medications:

“Do I really need them, or can I fix this with diet and exercise?”
“I’ve heard that once you start taking these tablets, you have to take them forever. Is that true?”

If the Candidate Mentions Lifestyle Changes:

“What exactly do I need to change?”
“I don’t want to stop eating all the things I enjoy.”
“I’ve tried quitting smoking before, but it never worked. What’s different this time?”

If the Candidate Dismisses the Patient’s Concerns:

“But my dad had a heart attack at my age. Isn’t that serious?”
“You’re saying it’s not serious now, but how do I know it won’t get worse?”

If the Candidate Pushes for Unnecessary Tests:

“I don’t want to waste money on unnecessary scans. Are they really needed?”

If the Candidate Suggests a Stress Test or Further Investigations:

“What will a stress test tell us?”
“Is there any way to check my arteries without doing a big test?”

Role-Playing Tips for the Candidate Assessment

You are concerned but not panicked. You just want to know what’s going on.
You don’t like taking medications. The candidate will need to provide a strong rationale.
If the candidate dismisses your concerns, push back. Ask about your family history and why you should/shouldn’t worry.
If the candidate is overly aggressive about tests, hesitate. You don’t want to spend money unless necessary.
If the candidate doesn’t mention smoking or diet, bring it up. Ask, “If I change my diet, will that be enough?”
If the candidate does not explain things well, ask for more information. For example, “What exactly does high cholesterol do to me?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I’ll think about what you said. I’m not sure about the tablets, but I guess I should at least start making some changes. I’ll talk to my wife about it and maybe book that follow-up appointment.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including cardiovascular risk factors and symptoms.

The competent candidate should:

Use open-ended questions to explore the patient’s chest discomfort, including onset, duration, nature, location, and aggravating or relieving factors.
Clarify whether symptoms are suggestive of angina, gastroesophageal reflux, musculoskeletal pain, or another cause.
Assess for red flags suggesting acute coronary syndrome (ACS), such as exertional symptoms, radiation to jaw/arm, associated nausea or diaphoresis, and nocturnal symptoms.
Obtain a detailed cardiovascular risk factor assessment, including hypertension, diabetes, dyslipidaemia, smoking, alcohol use, family history, and physical activity levels.
Discuss modifiable lifestyle factors, such as diet, exercise, and stress levels.
Identify patient concerns and expectations, particularly regarding medication hesitancy, potential need for investigations, and fear of heart attack.

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

Outline a differential diagnosis, including:
- Stable angina – exertional chest tightness relieved with rest, common in patients with cardiovascular risk factors.
- Gastro-oesophageal reflux disease (GORD) – worsened by meals, lying down, or certain foods.
- Musculoskeletal pain – localised, worsened by movement, and reproducible on palpation.
- Anxiety-related symptoms – often present with atypical or diffuse chest discomfort.
Explain that the symptoms are concerning for possible coronary artery disease (CAD), given the patient’s age, smoking history, family history, and hyperlipidaemia.
Recommend initial investigations, including:
- ECG – to assess for ischaemic changes.
- Fasting lipid profile and HbA1c – to assess cardiovascular risk factors.
- High-sensitivity troponin (if acute symptoms arise).
- Exercise stress test or CT coronary angiography (as appropriate, based on risk stratification).
Provide immediate safety netting advice, instructing the patient to seek urgent medical attention if they experience chest pain at rest, increasing frequency/severity of pain, or associated symptoms such as breathlessness, dizziness, or diaphoresis.

Task 3: Address the patient’s concerns regarding cardiovascular disease and medication use.

The competent candidate should:

Acknowledge and validate the patient’s concerns about cardiovascular disease, particularly their family history of heart attack.
Reassure that early detection and risk management can significantly reduce the chance of future cardiovascular events.
Address medication hesitancy by explaining:
- Statins lower cholesterol and stabilise plaques, reducing heart attack risk by up to 30%.
- Blood pressure management can prevent heart disease, stroke, and kidney damage.
- Medications are tailored to the individual, and side effects can be managed.
Highlight non-pharmacological interventions, including smoking cessation, dietary changes, and exercise, but stress that medication may still be necessary for high-risk individuals.
Offer shared decision-making, providing written resources and discussing a follow-up plan to monitor progress.

Task 4: Develop a comprehensive management plan, including lifestyle modifications and appropriate follow-up.

The competent candidate should:

Implement a lifestyle intervention strategy, including:
- Smoking cessation – referral to Quitline, nicotine replacement therapy (NRT), or pharmacotherapy (e.g., varenicline, bupropion).
- Dietary modifications – reducing saturated fats, increasing fibre, and incorporating the Mediterranean diet.
- Exercise recommendations – encouraging 150 minutes per week of moderate-intensity activity.
- Weight management – targeting BMI <25 kg/m².
Discuss pharmacological management:
- Statin therapy for LDL ≥2.6 mmol/L or high absolute cardiovascular risk.
- Antihypertensive therapy if BP consistently ≥140/90 mmHg.
- Aspirin if high cardiovascular risk (in discussion with cardiology if needed).
Arrange follow-up in 2-4 weeks to reassess symptoms, risk factor control, and response to lifestyle interventions.
Consider referral to a cardiologist for further risk stratification and potential stress testing or coronary imaging.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, identifying cardiovascular risk factors and potential red flags.
Uses a clinical reasoning approach to differentiate cardiac and non-cardiac causes of chest discomfort.
Reassures the patient while explaining the importance of risk factor modification.
Uses shared decision-making to address medication hesitancy and lifestyle modifications.
Provides clear safety-netting advice and establishes an appropriate follow-up plan.

PITFALLS

Failing to assess red flags (e.g., exertional symptoms, nocturnal angina, radiation to jaw/arm).
Over-investigating without appropriate risk stratification (e.g., ordering a stress test unnecessarily).
Dismissing patient concerns or not adequately addressing fears about medications.
Neglecting to offer lifestyle interventions, focusing solely on medications.
Lack of clear follow-up and safety netting, leaving the patient uncertain about next steps.

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including cardiovascular risk factors and symptoms.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and clinical reasoning.
3.2 Utilises cardiovascular risk assessment tools to stratify risk.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides lifestyle and pharmacological recommendations.
4.7 Ensures patient-centred shared decision-making.

5. Preventive and Population Health

5.1 Provides guidance on cardiovascular risk reduction.
5.2 Advises on lifestyle modifications, including diet and exercise.

Competency at Fellowship Level

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