CCE-CE-147.1

CASE INFORMATION

Case ID: CCE-CVD-003
Case Name: John Anderson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K92 – Atherosclerosis/Peripheral Vascular Disease (PVD)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages the patient
1.2 Explores the patient’s concerns, ideas, and expectations
1.3 Provides clear explanations about the condition and management options
2. Clinical Information Gathering and Interpretation2.1 Takes a thorough cardiovascular, lifestyle, and risk factor history
2.2 Assesses for symptoms of peripheral arterial disease (PAD) and atherosclerosis-related complications
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between PAD and other causes of leg pain (e.g., venous insufficiency, neuropathy)
3.2 Identifies patients requiring further investigations or specialist referral
4. Clinical Management and Therapeutic Reasoning4.1 Provides a structured, evidence-based management plan
4.2 Initiates pharmacological and non-pharmacological interventions for PAD
5. Preventive and Population Health5.1 Discusses modifiable risk factors, including smoking cessation, exercise, and diet
6. Professionalism6.1 Provides patient-centred, non-judgmental care
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate screening for cardiovascular risk and vascular complications
9. Managing Uncertainty9.1 Recognises atypical presentations and considers differential diagnoses
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies patients at high risk of cardiovascular events and initiates appropriate interventions

CASE FEATURES

  • Asks if he needs surgery or whether medication can help.
  • 67-year-old male presents with intermittent leg pain when walking.
  • History of hypertension and type 2 diabetes.
  • Long-term smoker (30 pack-year history).
  • Concerned about worsening walking distance and cold feet.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history, including cardiovascular risk factors, symptoms of PAD, and functional impact.
  2. Assess and explain the likely diagnosis of PAD, including differentiation from other causes of leg pain.
  3. Provide a structured management plan, including lifestyle modifications, pharmacotherapy, and indications for vascular specialist referral.
  4. Address the patient’s concerns about disease progression, complications, and treatment options.

SCENARIO

John Anderson, a 67-year-old retired builder, presents with gradually worsening pain in his calves when walking. He first noticed it a year ago, but it has become more limiting recently. He describes cramping pain in both calves after walking about 100 metres, which relieves with rest. His feet sometimes feel cold, and he has noticed slower healing of small cuts.

His main concerns include:

  • “Doctor, why do my legs hurt so much when I walk? Is it just old age?”
  • “I feel like I can’t walk as far as I used to. Will this get worse?”
  • “I’ve heard about surgery for circulation problems—will I need an operation?”
  • “I still smoke, but could quitting really help at this stage?”

His vascular risk factors include:

  • Hypertension (diagnosed 10 years ago, managed with amlodipine).
  • Type 2 diabetes (diagnosed 6 years ago, on metformin).
  • Long-term smoker (30 pack-year history, currently smokes 15 cigarettes per day).
  • Family history of heart disease—father had a heart attack at 58.

His medications include:

  • Amlodipine 5 mg daily.
  • Metformin 1 g BD.
  • Aspirin 100 mg daily (self-initiated after a friend recommended it).

PATIENT RECORD SUMMARY

Patient Details

Name: John Anderson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies.

Medications

  • Amlodipine 5 mg daily
  • Metformin 1 g BD
  • Aspirin 100 mg daily (self-initiated)

Past History

  • Hypertension (10 years).
  • Type 2 diabetes (6 years).

Social History

  • Retired builder.
  • Lives with wife.
  • Smokes 15 cigarettes per day.
  • Drinks alcohol occasionally.
  • Limited exercise due to leg pain.

Preventive Activities

  • No previous vascular assessment.
  • No recent lipid profile or HbA1c testing.

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, my legs cramp up every time I go for a walk, and I have to stop. I used to be able to walk for hours, but now I can’t even get to the shops without pain. What’s going on?”

General Information

You are John Anderson, a 67-year-old retired builder. Over the past year, you’ve noticed gradual worsening of pain in your calves when walking. At first, it only happened on long walks, but now you feel it after about 100 metres, forcing you to stop and rest. The pain eases within a few minutes, but it returns once you start walking again. You don’t get pain at rest, but you have cold feet sometimes, and you’ve noticed that small cuts on your legs seem to take longer to heal.

You’re concerned because you’re finding it harder to do daily activities, like walking to the shops or gardening. You want to know:

  • “Is this just old age, or is something wrong with my circulation?”
  • “Will this get worse? Am I going to lose a leg?”
  • “Will I need surgery for this?”
  • “I’ve heard smoking affects circulation, but is it too late to quit now?”
  • “Can I take medication instead of an operation?”

You’re still independent but worry about your mobility declining. You live with your wife, who has also been nagging you to quit smoking, but you haven’t been able to give up.

Specific Information (To be revealed only when asked)

Leg Symptoms

  • Pain/cramping in both calves after walking about 100 metres.
  • Pain resolves within a few minutes of stopping.
  • No pain at rest (but feet sometimes feel cold).
  • Noticed slower healing of small cuts on legs.
  • No leg swelling, redness, or warmth.

Medical and Lifestyle History

  • Hypertension (diagnosed 10 years ago, on amlodipine 5 mg daily).
  • Type 2 diabetes (diagnosed 6 years ago, on metformin 1 g BD).
  • Smokes 15 cigarettes/day (30 pack-year history).
  • Occasionally drinks alcohol.
  • No previous vascular assessment or testing.
  • No known history of heart attack or stroke.
  • No previous leg surgery or intervention.

Family History

  • Father had a heart attack at 58.

Emotional Cues and Responses

If the candidate is reassuring and provides a clear management plan:

  • You will feel relieved and motivated to make changes.
  • You will ask more about lifestyle modifications and treatment options.
  • You may express interest in smoking cessation if it will improve your walking ability.

If the candidate is dismissive or vague:

  • You may feel frustrated and disengaged.
  • You may doubt whether there’s anything you can do to help your condition.
  • You may express reluctance to take more medications.

If the candidate discusses smoking cessation in a supportive way:

  • You will acknowledge that you’ve tried quitting before but failed.
  • You may express interest in trying again if the doctor offers a structured approach.

If the candidate strongly pushes for immediate smoking cessation without support:

  • You may become defensive and say that quitting is too difficult.

Questions for the Candidate

  1. “Do I need surgery for this?”
  2. “Can this get better, or will it just keep getting worse?”
  3. “Is this why my feet are cold sometimes?”
  4. “Can I take medication instead of an operation?”
  5. “I still smoke, but does quitting really help at my age?”
  6. “Is this because of my diabetes?”
  7. “What kind of exercise can I do if walking makes it worse?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear, structured plan:

  • You will feel reassured and more willing to follow treatment recommendations.
  • You will ask more about smoking cessation, lifestyle changes, and medication options.
  • You will express some concerns but will be open to following up for further management.

If the candidate is unclear or dismissive:

  • You may feel frustrated and concerned about your worsening mobility.
  • You might be less willing to make lifestyle changes or take medication.
  • You may seek a second opinion elsewhere.

If the candidate is overly forceful about smoking cessation without addressing your other concerns:

  • You may become defensive and say that quitting is too difficult.
  • You may resist further discussion about lifestyle changes.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including cardiovascular risk factors, symptoms of peripheral arterial disease (PAD), and functional impact.

The competent candidate should:

  • Elicit details about leg symptoms, including:
    • Nature of pain (cramping, burning, aching).
    • Claudication distance (how far can the patient walk before pain starts?).
    • Relief with rest (suggestive of PAD).
    • Any rest pain (suggests critical limb ischaemia).
    • Skin changes (cold feet, ulcers, slow healing wounds).
  • Assess cardiovascular risk factors, including:
    • Smoking history (current and past use).
    • Hypertension, diabetes, dyslipidaemia, family history of cardiovascular disease.
    • Medications and adherence.
  • Evaluate functional impact, including:
    • Limitations in walking ability.
    • Impact on daily activities and quality of life.

Task 2: Assess and explain the likely diagnosis of PAD, including differentiation from other causes of leg pain.

The competent candidate should:

  • Explain PAD in simple terms:
    • Narrowing of arteries due to plaque buildup, reducing blood flow to the legs.
    • Causes pain (claudication) due to inadequate oxygen supply to muscles during activity.
  • Differentiate PAD from other causes of leg pain:
    • PAD: Pain with exertion, relieved by rest, often with cold feet or slow-healing wounds.
    • Chronic venous insufficiency: Swelling, aching, worse with prolonged standing, improves with leg elevation.
    • Neuropathy (diabetes-related): Burning pain, tingling, numbness, not related to exertion.
    • Spinal stenosis: Pain or weakness worsens with standing, relieved by bending forward.
  • Discuss the need for further assessment, including:
    • Ankle-Brachial Index (ABI) for objective PAD assessment.
    • Doppler ultrasound for vascular imaging if needed.

Task 3: Provide a structured management plan, including lifestyle modifications, pharmacotherapy, and indications for vascular specialist referral.

The competent candidate should:

  • Lifestyle modifications:
    • Smoking cessation (most effective intervention to slow disease progression).
    • Structured exercise program (supervised walking to improve collateral circulation).
    • Healthy diet (reduce saturated fats, increase fibre, Mediterranean diet).
    • Weight loss if overweight.
  • Pharmacotherapy:
    • Antiplatelet therapy (aspirin or clopidogrel) to reduce cardiovascular risk.
    • Statin therapy (atorvastatin 40-80 mg) to reduce plaque progression.
    • Blood pressure control (ACE inhibitors, calcium channel blockers).
    • Diabetes optimisation (aim for HbA1c <7%).
  • Referral to a vascular specialist if:
    • Symptoms significantly impact daily life despite conservative management.
    • Rest pain, ulceration, or signs of critical limb ischaemia.

Task 4: Address the patient’s concerns about disease progression, complications, and treatment options.

The competent candidate should:

  • Reassure that early intervention can prevent complications.
  • Explain that surgery (angioplasty or bypass) is only considered in severe cases.
  • Clarify that quitting smoking and regular walking can significantly improve symptoms.
  • Discuss the importance of medication adherence in reducing stroke/heart attack risk.

SUMMARY OF A COMPETENT ANSWER

  • Takes a thorough history of PAD symptoms, risk factors, and functional limitations.
  • Differentiates PAD from other causes of leg pain.
  • Explains the condition in patient-friendly language.
  • Provides a structured, evidence-based management plan.
  • Addresses patient concerns about prognosis, surgery, and smoking cessation.

PITFALLS

  • Failing to assess the impact of symptoms on daily function.
  • Not differentiating PAD from other causes of leg pain (neuropathy, venous insufficiency).
  • Overlooking the importance of smoking cessation.
  • Not offering a structured exercise program.
  • Failing to explain that PAD is a systemic vascular disease with increased cardiovascular risk.

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, and expectations.
1.3 Provides a clear and structured explanation of PAD management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough vascular history and assesses functional limitations.
2.2 Identifies key cardiovascular risk factors and their contribution to PAD.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between PAD and other causes of leg pain.
3.2 Recognises when specialist referral is needed.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an appropriate stepwise treatment plan.
4.2 Discusses pharmacological and lifestyle interventions.

5. Preventive and Population Health

5.1 Emphasises smoking cessation, exercise, and cardiovascular risk reduction.

6. Professionalism

6.1 Provides patient-centred, non-judgmental care.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate screening for cardiovascular complications.

9. Managing Uncertainty

9.1 Recognises atypical presentations and considers alternative diagnoses.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies patients at high risk of cardiovascular events and initiates appropriate interventions.

Competency at Fellowship Level

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