CASE INFORMATION

Case ID: PH-002
Case Name: Mary Williams
Age: 62
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A44 (Preventive Immunisation/Medication), Z30 (Routine Health Maintenance), K74 (Ischaemic Heart Disease Without Angina).

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to gather information about their health status and preventive needs. 1.2 Communicates effectively to educate the patient about preventive health interventions.
2. Clinical Information Gathering and Interpretation	2.1 Takes a targeted history regarding risk factors for vaccine-preventable diseases and chronic disease prevention.
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies risk factors and determines appropriate preventive health strategies.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based preventive health plan, including vaccinations, screening, and lifestyle advice.
5. Preventive and Population Health	5.1 Implements national guidelines for immunisations and chronic disease screening.
6. Professionalism	6.1 Provides patient-centred care while respecting patient autonomy in preventive decisions.
7. General Practice Systems and Regulatory Requirements	7.1 Understands Medicare-funded health assessments and immunisation programs.
8. Procedural Skills	8.1 Demonstrates correct immunisation technique and documentation.
9. Managing Uncertainty	9.1 Addresses vaccine hesitancy and unclear preventive health history.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies patients at high risk for vaccine-preventable illnesses and cardiovascular disease.

CASE FEATURES

62-year-old woman presenting for a routine check-up.
Uncertain about her vaccination status.
Risk factors for cardiovascular disease.
Requires age-appropriate cancer screening and chronic disease prevention strategies.
Opportunity to educate on preventive health.

Candidate Information

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Mary Williams
Age: 62
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Atorvastatin 20mg daily
Perindopril 5mg daily

Past History

Hyperlipidaemia
Hypertension
Borderline Type 2 Diabetes

Social History

Retired schoolteacher
Lives alone, has two adult children
Walks occasionally, but not regularly
Diet includes processed foods and minimal vegetables

Family History

Mother had breast cancer at 65
Father had a stroke at 70
No known family history of diabetes

Smoking

Quit 10 years ago, previously smoked 20 cigarettes/day for 30 years

Alcohol

Drinks 1-2 standard drinks per week

Vaccination and Preventative Activities

Influenza vaccine: Unknown
Pneumococcal vaccine: Uncertain
COVID-19 vaccine: 2 doses, last in 2021
Cervical screening test: Normal 5 years ago
Mammogram: 2 years ago, normal
Bowel cancer screening: Never done

SCENARIO

Mary Williams, a 62-year-old woman, presents for a routine health check. She mentions that she has not seen a doctor in over two years and is unsure if she is up to date with her vaccinations. She does not recall ever receiving a pneumococcal or shingles vaccine.

She is generally well but has a history of hypertension, hyperlipidaemia, and borderline Type 2 diabetes. She quit smoking 10 years ago but previously had a 30-pack-year history. She is unsure whether she needs any further health checks or vaccinations.

She reports mild fatigue but attributes this to aging. She does not regularly exercise and has a diet low in vegetables. She denies chest pain, shortness of breath, or other symptoms of concern.

On examination:

General Appearance: Well-appearing, BMI 29
Temperature: 36.6°C
Blood Pressure: 140/88 mmHg
Heart Rate: 78 bpm, regular
Respiratory Rate: 16 breaths per minute
Oxygen Saturation: 98% on room air
Other Examination Findings:

No carotid bruits
Normal heart sounds, no murmurs
No signs of diabetic neuropathy
Normal breast and abdominal exam

INVESTIGATION FINDINGS

Pending investigations include:

Fasting lipid profile
HbA1c
Renal function (eGFR, creatinine)
ECG
FIT (Faecal Immunochemical Test) for bowel cancer screening

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess Mary’s preventive healthcare needs?

Prompt: What specific lifestyle and medical history factors would influence her preventive care?
Prompt: How would you assess her vaccination history if uncertain?

Q2. What immunisations are recommended for Mary based on her age and risk factors?

Prompt: What are the key vaccines recommended for adults aged ≥60?
Prompt: What additional vaccinations might be considered given her medical history?

Q3. What other preventive health measures should be discussed with Mary?

Prompt: What cancer screening tests are appropriate for her age?
Prompt: What lifestyle modifications would you recommend?

Q4. How would you address vaccine hesitancy if Mary expresses concerns about vaccinations?

Prompt: How would you explain the benefits of vaccinations in a patient-centred manner?
Prompt: What strategies can be used to encourage vaccine uptake?

Q5. Mary is found to have an elevated HbA1c and LDL cholesterol. What are your next steps?

Prompt: What further investigations or referrals are needed?
Prompt: How would you modify her treatment plan?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess Mary’s preventive healthcare needs?

A comprehensive history is essential to tailor preventive healthcare strategies to Mary’s individual needs. Key areas to explore include:

1. Vaccination History:

Previous influenza, pneumococcal, and shingles vaccinations.
Any prior adverse reactions to vaccines.
COVID-19 booster status (last dose in 2021, requiring update).

2. Cardiovascular and Metabolic Risk Factors:

Dietary habits: Intake of saturated fats, refined carbohydrates, salt.
Physical activity: Frequency, type, barriers to exercise.
Smoking history: Detailed pack-years, history of nicotine dependence.
Alcohol consumption: Type, quantity, frequency.

3. Cancer Screening History:

Breast cancer: Any previous mammograms, last one was two years ago.
Bowel cancer: Never had a Faecal Immunochemical Test (FIT)—should be performed.
Cervical cancer: Last cervical screening test was five years ago—needs update.

4. Bone Health and Falls Risk:

History of fractures, osteoporosis, or falls.
Menopausal status and risk factors for osteopenia/osteoporosis.

5. Psychosocial and Mental Health:

Mood symptoms, sleep patterns, social support.
Stress levels and coping mechanisms.

This targeted history ensures a comprehensive, patient-centred preventive health approach.

Q2: What immunisations are recommended for Mary based on her age and risk factors?

According to Australian Immunisation Guidelines, the following vaccines are recommended:

1. Influenza Vaccine (Annual)

Recommended due to age and cardiovascular risk factors.

2. Pneumococcal Vaccine

Pneumovax 23 (one dose at age ≥65) for protection against pneumococcal pneumonia.

3. Herpes Zoster (Shingles) Vaccine

Shingrix (two doses, ≥60 years) or Zostavax (one dose, ≥70 years, if immunocompetent).

4. COVID-19 Booster

Recommended as she received her last dose in 2021.

5. Tetanus, Diphtheria, Pertussis (dTpa) Booster

Single dose every 10 years (if not recently received).

6. Hepatitis B Vaccine

Consider if no documented immunity.

Q3: What other preventive health measures should be discussed with Mary?

Mary’s preventive health strategy should include:

1. Cardiovascular Risk Management:

BP monitoring, lipid profile, HbA1c to assess CVD risk.
Lifestyle modifications: diet, exercise, smoking cessation.

2. Cancer Screening:

Mammogram (every two years, as per BreastScreen Australia).
Bowel cancer screening (FIT every two years from age 50-74).
Cervical screening test (every five years until age 74).

3. Bone Health:

DEXA scan if high-risk for osteoporosis.
Calcium and vitamin D supplementation if deficient.

4. Mental Health and Social Well-being:

Discuss mental health screening if indicated.
Encourage social engagement and mental stimulation.

Q4: How would you address vaccine hesitancy if Mary expresses concerns about vaccinations?

If Mary is hesitant about vaccines, a patient-centred, evidence-based approach is crucial.

1. Acknowledge Concerns:

Actively listen and explore specific fears (e.g., side effects, efficacy).

2. Provide Clear, Evidence-Based Information:

Explain benefits outweigh risks, especially in older adults with CVD risk.
Use statistics: Influenza vaccination reduces hospitalisation risk by up to 45%.

3. Address Misinformation:

Reassure about safety and efficacy, referencing ATAGI guidelines.
Clarify common myths (e.g., vaccines do not cause influenza).

4. Offer Shared Decision-Making:

Provide written materials or refer to credible sources (e.g., Health.gov.au).
Encourage gradual decision-making: “You can start with the flu vaccine today and decide on the others later.”

Q5: Mary is found to have an elevated HbA1c and LDL cholesterol. What are your next steps?

Mary’s results suggest early Type 2 diabetes and dyslipidaemia, requiring multifaceted management.

1. Confirm and Stratify Risk:

Repeat HbA1c, fasting glucose, and lipid profile.
Calculate CVD risk score.

2. Lifestyle Modification:

Diet: Increase fibre, reduce refined carbs, incorporate Mediterranean diet.
Exercise: Encourage ≥150 minutes/week of moderate activity.

3. Pharmacological Management:

Metformin initiation if HbA1c ≥6.5%.
Statin therapy (e.g., atorvastatin) if 10-year CVD risk is high.

4. Long-Term Monitoring & Follow-Up:

HbA1c every 3-6 months.
BP monitoring and annual diabetes complications screening.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking covering vaccinations, lifestyle, and screening history.
Clear recommendations on immunisations based on Australian guidelines.
Structured approach to preventive health, including cancer screening and cardiovascular risk management.
Empathetic approach to vaccine hesitancy, using evidence-based counselling techniques.
Practical management plan for early Type 2 diabetes and dyslipidaemia.

PITFALLS

Failure to address vaccine history in detail.
Missing key preventive health interventions, such as bowel cancer screening.
Inadequate counselling on lifestyle modifications, focusing only on pharmacotherapy.
Not addressing vaccine hesitancy appropriately, leading to refusal of immunisation.
Overlooking cardiovascular and diabetes risk factors, delaying appropriate intervention.

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 sociocultural context.
1.2 Engages the patient to gather information about their symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a targeted history regarding risk factors for vaccine-preventable diseases.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies risk factors and determines appropriate preventive health strategies.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based preventive health plan.

Competency at Fellowship Level

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