CASE INFORMATION

Case ID: CC-2025-001
Case Name: John Williams
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K30 (Cardiovascular check-up), K86 (Hypertension), K74 (Ischaemic heart disease without angina)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively 1.3 Elicits patient’s concerns and expectations 1.5 Provides clear and tailored health education
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including cardiovascular risk factors 2.3 Performs targeted physical examination 2.4 Orders and interprets appropriate investigations
3. Diagnosis, Decision-Making and Reasoning	3.2 Assesses cardiovascular risk 3.3 Forms a working diagnosis 3.5 Identifies red flags requiring urgent intervention
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based management plan 4.4 Prescribes appropriate pharmacological therapy 4.6 Addresses lifestyle modifications
5. Preventive and Population Health	5.1 Implements cardiovascular disease prevention strategies 5.2 Discusses smoking cessation, diet, and exercise
6. Professionalism	6.2 Demonstrates patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Documents consultation and investigation results appropriately
9. Managing Uncertainty	9.1 Considers possible cardiovascular differential diagnoses
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages high-risk cardiovascular patients

CASE FEATURES

Middle-aged male presenting for a routine cardiac check-up
History of mild hypertension and hypercholesterolemia
Lifestyle risk factors: obesity, sedentary lifestyle, diet high in processed foods
No current symptoms but has a family history of coronary artery disease
Interpretation of cardiovascular risk score and next steps

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 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: John Williams
Age: 58
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 5 mg daily (for hypertension)
Atorvastatin 20 mg daily (for hypercholesterolemia)

Past History

Diagnosed hypertension 3 years ago
Hypercholesterolemia (on statin therapy)
No previous cardiac events

Social History

Works as an accountant, sedentary lifestyle
Married, 2 children
Eats processed foods regularly, low vegetable intake
Exercises <1x per week
BMI: 29.5 kg/m²

Family History

Father had an MI at age 62
Mother had Type 2 Diabetes

Smoking

Smoked 10-15 cigarettes daily for 15 years, quit 5 years ago

Alcohol

10-12 standard drinks per week

Vaccination and Preventative Activities

Up-to-date with influenza and COVID-19 vaccines
Last lipid panel: 6 months ago, LDL 3.8 mmol/L

SCENARIO

John Williams, a 58-year-old male, presents for a routine cardiac check-up. He has been diagnosed with mild hypertension and hypercholesterolemia but has not had any cardiovascular events. He is currently taking amlodipine and atorvastatin.

He has no current symptoms of chest pain, dyspnoea, dizziness, or palpitations but is concerned about his family history of heart disease. He admits to low physical activity, a diet high in processed foods, and occasional alcohol overconsumption.

He is interested in knowing whether he is at high risk of a heart attack and if he needs further tests. He has read about coronary calcium scoring and wants to discuss whether this is appropriate.

EXAMINATION FINDINGS

General Appearance: Overweight, no distress
Blood Pressure: 138/85 mmHg
Heart Rate: 78 bpm, regular
Respiratory Rate: 16 breaths/min
Oxygen Saturation: 98% on room air
BMI: 29.5 kg/m²
Cardiovascular: No murmurs, no peripheral oedema
Lungs: Clear to auscultation

INVESTIGATION FINDINGS

Recent Blood Results

Total Cholesterol: 5.8 mmol/L (normal <5.5)
LDL: 3.8 mmol/L (normal <3.0)
HDL: 1.0 mmol/L (normal >1.0)
Triglycerides: 2.0 mmol/L (normal <1.7)
Fasting Glucose: 5.4 mmol/L

ECG: Normal sinus rhythm, no ST changes
Exercise Stress Test: Not yet performed

EXAMINER ONLY INFORMATION

QUESTIONS

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

Prompt: Ask about symptoms such as exertional chest pain, dyspnoea, or palpitations.
Prompt: Explore stress levels, sleep quality, and erectile dysfunction.

Q2. How would you assess John’s cardiovascular risk using available tools?

Prompt: Explain how the Absolute Cardiovascular Risk Calculator works.
Prompt: Discuss coronary calcium scoring indications.

Q3. What investigations would you order, and why?

Prompt: Justify the role of fasting lipid profile, HbA1c, and ECG.
Prompt: Discuss if an exercise stress test or echocardiogram is needed.

Q4. What are the key lifestyle modifications you would recommend?

Prompt: Provide tailored advice on diet, exercise, and smoking cessation.
Prompt: Address alcohol intake and stress management.

Q5. What pharmacological changes, if any, would you consider?

Prompt: Would you intensify lipid-lowering therapy?
Prompt: Would you consider adding low-dose aspirin?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

A comprehensive history is essential to accurately assess John’s cardiovascular risk. The candidate should systematically explore key areas:

1. Cardiovascular Symptoms

Ask about exertional chest pain, dyspnoea, palpitations, dizziness, syncope, and fatigue.
Explore nocturnal dyspnoea or orthopnoea, which may suggest heart failure.
Ask about leg swelling (peripheral oedema), a possible sign of cardiac dysfunction.

2. Risk Factors and Lifestyle

Dietary habits: High-salt, high-saturated fat, processed foods intake.
Exercise patterns: Frequency, intensity, and type of physical activity.
Alcohol consumption: Weekly intake, binge drinking patterns.
Smoking history: Previously smoked for 15 years—assess potential residual risk.
Psychosocial stress: Work, sleep quality, family stressors.

3. Family History

First-degree relatives with cardiovascular disease (CVD), including early myocardial infarction (men <55 years, women <65 years).
History of stroke, hypertension, dyslipidaemia, diabetes, or sudden cardiac death in the family.

4. Hypertension and Medication Adherence

Blood pressure monitoring at home?
Medication compliance: Adherence to amlodipine and atorvastatin.
Any side effects leading to non-compliance?

5. Erectile Dysfunction

Assess for erectile dysfunction, which is an early marker of vascular disease.

6. Sleep and Stress Factors

Obstructive Sleep Apnoea (OSA): Loud snoring, daytime fatigue, witnessed apnoea.
Mental health: Depression, anxiety, work stress, poor sleep.

By gathering this history, a more precise cardiovascular risk profile can be established, allowing for targeted management and preventive strategies.

Q2: How would you assess John’s cardiovascular risk using available tools?

John’s cardiovascular risk should be assessed using the Australian Absolute Cardiovascular Risk Calculator, which integrates multiple risk factors to estimate 5-year CVD risk.

1. Absolute Cardiovascular Risk Calculation

Age, gender
Systolic blood pressure (138 mmHg)
Lipid profile (Total Cholesterol 5.8 mmol/L, LDL 3.8 mmol/L, HDL 1.0 mmol/L)
Diabetes status (Fasting glucose 5.4 mmol/L)
Smoking status (Ex-smoker, quit 5 years ago)
Family history of premature CVD
Presence of atrial fibrillation (not present)

2. Coronary Artery Calcium (CAC) Score

Consider for intermediate-risk patients to guide statin therapy decisions.
Recommended if John is uncertain about statin use or wants a better risk stratification.

3. Other Risk Modifiers

hs-CRP (High-sensitivity C-reactive protein): Useful if inflammatory risk suspected.
Lp(a) (Lipoprotein a): Consider if premature CVD in family.

4. Interpretation of Risk Score

Low risk: <10% 5-year risk
Intermediate risk: 10-15%
High risk: >15% → Strong indication for intensive intervention

John’s likely moderate-to-high risk status justifies more aggressive lipid-lowering strategies and lifestyle changes.

Q3: What investigations would you order, and why?

1. Blood Tests

Fasting Lipid Profile: Evaluate LDL targets for optimal therapy.
HbA1c: Rule out insulin resistance and pre-diabetes.
Renal Function (eGFR, UECs): Check for hypertension-related kidney disease.
Liver Function Tests: Monitor statin effects.

2. ECG

Detect silent ischaemia, arrhythmias, LVH.
Particularly relevant given hypertension and family history of CAD.

3. Exercise Stress Test (if indicated)

Consider if intermediate-high risk with symptoms.
Not needed if asymptomatic with low-risk ECG.

4. Echocardiogram

Assess LV function, hypertrophy, or valvular disease if indicated.

These investigations help refine cardiovascular risk stratification and guide targeted intervention.

Q4: What are the key lifestyle modifications you would recommend?

1. Diet Changes

DASH diet: Reduce sodium intake, processed foods, and red meats.
Increase omega-3s (fatty fish), whole grains, and fibre.

2. Physical Activity

At least 150 minutes of moderate-intensity exercise per week.
Include resistance training to lower CVD risk.

3. Weight Management

Target BMI <25 kg/m² to reduce hypertension and dyslipidaemia.

4. Smoking & Alcohol

Reinforce smoking cessation benefits.
Limit alcohol to <10 standard drinks per week.

5. Stress Management & Sleep

Address work stress and sleep hygiene.
Consider referral for OSA assessment if indicated.

John’s primary prevention plan should focus on modifiable risk factors with behavioural coaching and GP follow-up.

Q5: What pharmacological changes, if any, would you consider?

1. Statin Therapy Adjustment

Increase atorvastatin to 40 mg daily (target LDL <2.0 mmol/L).
Consider ezetimibe if LDL remains high.

2. Antihypertensive Review

Target BP <130/80 mmHg for high-risk patients.
Consider adding ACE inhibitor if end-organ effects develop.

3. Low-Dose Aspirin?

Only if high absolute CVD risk (>15%).
Weigh bleeding risk carefully.

Regular review should ensure adherence, safety, and treatment goals.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering symptoms, risk factors, family history, lifestyle.
Use of evidence-based risk calculators to guide CVD risk stratification.
Appropriate investigations, including lipids, ECG, and secondary tests if indicated.
Tailored lifestyle recommendations, focusing on diet, exercise, weight, smoking, and stress.
Rational pharmacological adjustments, considering statin titration and antihypertensives.

PITFALLS

Missing key risk factors (e.g., sleep apnoea, erectile dysfunction, medication adherence).
Not using absolute risk tools, leading to misclassification of cardiovascular risk.
Inappropriate over-ordering (e.g., routine stress test without indication).
Failure to prioritise lifestyle interventions before escalating pharmacotherapy.
Recommending aspirin without assessing bleeding 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

Competency at Fellowship Level

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