CASE INFORMATION

Case ID: LIP-006
Case Name: David Thompson
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T93 (Lipid Disorder), 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 lifestyle, cardiovascular risk, and health concerns. 1.2 Provides clear explanations regarding lipid disorders and cardiovascular risk in a patient-centred manner.
2. Clinical Information Gathering and Interpretation	2.1 Conducts a comprehensive assessment of cardiovascular risk factors.
3. Diagnosis, Decision-Making and Reasoning	3.1 Uses lipid profile results and cardiovascular risk assessment tools to determine disease severity and need for intervention.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an individualised management plan including pharmacological and non-pharmacological strategies.
5. Preventive and Population Health	5.1 Implements strategies to prevent cardiovascular events through lifestyle interventions and lipid control.
6. Professionalism	6.1 Maintains a patient-centred approach, ensuring shared decision-making.
7. General Practice Systems and Regulatory Requirements	7.1 Understands Medicare-funded chronic disease management plans and lipid-lowering therapy guidelines.
8. Procedural Skills	8.1 Performs relevant clinical examinations (e.g., BP, BMI, fundoscopy, peripheral pulses).
9. Managing Uncertainty	9.1 Recognises when specialist referral (e.g., lipidologist, cardiologist) is warranted.
10. Identifying and Managing the Patient with Significant Illness	10.1 Detects and manages high cardiovascular risk patients appropriately.

CASE FEATURES

47-year-old male presenting for a routine health check, recently found to have elevated cholesterol levels.
No history of cardiovascular disease (CVD) but strong family history of premature heart disease.
Overweight (BMI 29), mild hypertension (BP 138/88 mmHg), poor dietary habits.
Lipid profile: Total cholesterol 6.8 mmol/L, LDL 4.5 mmol/L, HDL 1.0 mmol/L, Triglycerides 2.3 mmol/L.
Requires cardiovascular risk stratification and lipid-lowering intervention.
Needs education on dietary and lifestyle modification.

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: David Thompson
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil current medications

Past History

Mild hypertension (diagnosed 1 year ago, not on medication)
Overweight (BMI 29)

Social History

Works as a business manager, desk job, minimal physical activity.
Diet high in red meat, fried foods, processed snacks.
No regular exercise apart from occasional walks.
Married, two teenage children.

Family History

Father had a myocardial infarction at 50.
Mother has hypercholesterolaemia, on statin therapy.
No known diabetes in the family.

Smoking

Never smoked.

Alcohol

8-10 standard drinks per week, mostly on weekends.

Vaccination and Preventative Activities

No recent cardiovascular risk screening.
Last general health check 3 years ago.

SCENARIO

David Thompson, a 47-year-old male, presents for a routine check-up after his workplace offered free cholesterol screening. His lipid profile shows:

Total cholesterol: 6.8 mmol/L (elevated)
LDL cholesterol: 4.5 mmol/L (elevated)
HDL cholesterol: 1.0 mmol/L (low)
Triglycerides: 2.3 mmol/L (mildly elevated)

He has no prior history of cardiovascular events but is overweight, hypertensive, and has a strong family history of heart disease. His blood pressure today is 138/88 mmHg.

David is concerned about his cholesterol levels and asks if he will need medication. He is keen to understand his risk and options for prevention but acknowledges his diet is not ideal, and he is not physically active.

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess David’s cardiovascular risk?

Prompt: What specific lifestyle and medical factors contribute to his risk?
Prompt: How would you determine his absolute cardiovascular risk?

Q2. What investigations would you order to assess his lipid disorder and overall cardiovascular risk?

Prompt: What additional tests are required for risk stratification?
Prompt: How do these tests guide management?

Q3. Outline your initial management plan for David, including lifestyle and pharmacological interventions.

Prompt: When would you start a statin, and at what intensity?
Prompt: How would you support lifestyle modification?

Q4. How would you educate David on his lipid disorder and cardiovascular risk?

Prompt: How would you explain his absolute cardiovascular risk?
Prompt: How would you motivate him to adhere to lifestyle changes?

Q5. David returns in six months with persistently elevated cholesterol despite lifestyle changes. What would you do next?

Prompt: How would you escalate pharmacological management?
Prompt: When would you refer to a specialist?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess David’s cardiovascular risk?

A thorough history is essential to assess David’s cardiovascular risk accurately.

1. Lifestyle Factors:

Diet: Consumption of saturated fats, processed foods, fruit/vegetable intake.
Physical Activity: Exercise type, duration, frequency.
Alcohol: Weekly intake, binge drinking episodes.
Stress levels: Work stress, sleep quality, mental well-being.

2. Cardiovascular Risk Factors:

Hypertension: Any previous high BP readings or symptoms (headaches, dizziness).
Diabetes Symptoms: Polyuria, polydipsia, weight loss.
Family History: Early-onset heart disease (<55 years in men, <65 years in women).

3. Medication and Past Medical History:

Previous lipid levels and trends.
Use of supplements or over-the-counter medications that may affect lipids.

4. Symptoms of Cardiovascular Disease:

Chest pain, dyspnoea, exertional fatigue, palpitations.
Claudication (suggestive of peripheral arterial disease).

5. Psychosocial Considerations:

Health literacy regarding lipid disorders and heart disease.
Motivation and readiness for lifestyle changes.

A structured history helps determine absolute cardiovascular risk and guides management.

Q2: What investigations would you order to assess his lipid disorder and overall cardiovascular risk?

Investigations should assess lipid levels, metabolic health, and cardiovascular risk.

1. Lipid and Metabolic Panel:

Fasting Lipid Profile: Confirms dyslipidaemia and subtype (LDL, HDL, triglycerides).
Fasting Blood Glucose / HbA1c: Screens for diabetes or insulin resistance.
Liver Function Tests (LFTs): Baseline before statin therapy.

2. Cardiovascular Risk Stratification:

ECG: Screens for silent ischaemia, arrhythmias.
Blood Pressure Monitoring: Confirms hypertension diagnosis.
Coronary Artery Calcium Score (if high risk and uncertain need for statins).

3. Secondary Causes of Dyslipidaemia (if severe or atypical):

TSH: Rules out hypothyroidism.
Renal Function (eGFR): Assesses for nephrotic syndrome or chronic kidney disease.

These tests help risk stratify and tailor interventions to prevent cardiovascular events.

Q3: Outline your initial management plan for David, including lifestyle and pharmacological interventions.

Management should be individualised based on absolute cardiovascular risk.

1. Lifestyle Modifications (First-Line):

Diet: Mediterranean diet, reduced saturated fats, increased fibre.
Exercise: 150 minutes of moderate-intensity activity per week.
Weight Management: Target BMI <25 through caloric control.
Alcohol Reduction: Limit to ≤2 standard drinks/day, alcohol-free days.

2. Pharmacological Therapy (Based on Risk):

Statin Indication: If 5-year CVD risk >10% (moderate-high risk) OR LDL >4.0 mmol/L.
First-line statin: Atorvastatin 20-40mg or rosuvastatin 10-20mg.
Ezetimibe if statin intolerant or inadequate response.

3. Follow-Up & Monitoring:

Lipid profile every 6-12 weeks initially, then 6-12 months.
Regular BP and diabetes screening.
Medication adherence and lifestyle support.

A combined lifestyle-pharmacological approach optimises long-term outcomes.

Q4: How would you educate David on his lipid disorder and cardiovascular risk?

David requires clear, patient-centred education about lipid disorders.

1. Explain His Lipid Profile & Risk:

High LDL = Increased risk of heart attack and stroke.
Low HDL and high triglycerides = Additional risk factors.

2. Absolute Cardiovascular Risk Assessment:

Use Australian Cardiovascular Risk Calculator.
Explain that lifestyle alone may not be sufficient if risk is moderate-high.

3. Address Concerns About Medication:

Statins reduce heart attack risk by 25-30%.
Minimal side effects, and regular monitoring ensures safety.

4. Encourage Lifestyle Changes:

Small changes make a big difference – diet, exercise, and alcohol moderation.
Set realistic, achievable goals.

Clear, structured education improves engagement and adherence.

Q5: David returns in six months with persistently elevated cholesterol despite lifestyle changes. What would you do next?

David’s cholesterol remains high, indicating further intervention is required.

1. Assess Adherence and Barriers:

Dietary compliance, exercise habits, medication adherence.
Assess side effects or statin intolerance.

2. Escalate Pharmacological Therapy:

Increase statin dose (e.g., atorvastatin 40-80mg or rosuvastatin 20-40mg).
Consider adding ezetimibe if LDL remains >2.6 mmol/L.
PCSK9 inhibitors (e.g., evolocumab) if very high-risk and statin-resistant.

3. Consider Specialist Referral (Lipidologist/Cardiologist):

Familial hypercholesterolaemia suspected (LDL >5.0, strong family history).
Statin intolerance despite multiple trials.

4. Reinforce Lifestyle Modifications:

Regular exercise, Mediterranean diet, alcohol moderation.
Review progress and follow up every 3-6 months.

A stepwise escalation ensures optimal lipid control and CVD risk reduction.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking covering diet, lifestyle, family history, and risk factors.
Appropriate investigations including lipid panel, diabetes screening, and cardiovascular risk assessment.
Evidence-based management, balancing lifestyle changes and medication initiation.
Patient-centred education, explaining cardiovascular risk and treatment benefits.
Timely treatment escalation if lifestyle alone is inadequate, with specialist referral if required.

PITFALLS

Failure to assess absolute cardiovascular risk using validated tools.
Delaying statin therapy despite high LDL and family history.
Not addressing lifestyle modifications alongside pharmacological therapy.
Poor patient education, leading to non-adherence.
Failure to recognise familial hypercholesterolaemia in high LDL cases.

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

Competency at Fellowship Level

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