EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for James’ symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigation?

• Prompt: What findings would prompt an emergency department referral?
• Prompt: What further tests would be appropriate?

Q3. How would you manage James’ condition?

• Prompt: What lifestyle modifications would you recommend?
• Prompt: When would you consider pharmacological therapy?

Q4. James is concerned about his risk of a heart attack. How would you counsel him?

• Prompt: How would you explain cardiovascular risk assessment?
• Prompt: How can you support behaviour change to reduce his risk?

Q5. What preventive strategies can James implement to reduce his cardiovascular risk?

• Prompt: What lifestyle changes are most effective?
• Prompt: What role do medications play in prevention?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for James’ symptoms?

James’ most likely diagnosis is stable angina, given his exertional chest discomfort relieved by rest, multiple cardiovascular risk factors (hypertension, hypercholesterolaemia, smoking, sedentary lifestyle, and family history), and absence of acute symptoms such as rest pain or syncope.

Key differential diagnoses include:

1. Acute Coronary Syndrome (ACS) – Unstable angina or myocardial infarction (consider if symptoms occur at rest or increase in intensity).
2. Gastro-oesophageal Reflux Disease (GORD) – Consider if symptoms occur postprandially, worsen with lying down, and improve with antacids.
3. Musculoskeletal Chest Pain (Costochondritis) – More likely if localised tenderness is present.
4. Aortic Stenosis – Consider if there is exertional syncope, murmur, or heart failure signs.
5. Pulmonary Embolism (PE) – Unlikely without sudden-onset dyspnoea, tachycardia, or hypoxia.

A focused history, examination, and ECG help differentiate cardiac from non-cardiac causes.

---

Q2: What red flags would indicate the need for urgent referral or further investigation?

Red flag symptoms requiring emergency referral:

• Chest pain at rest or lasting >20 minutes
• Increasing frequency or severity of pain
• Pain radiating to jaw, left arm, or back
• Associated symptoms: diaphoresis, nausea, dyspnoea, syncope

Examination findings that warrant escalation:

• Hypotension or arrhythmia
• New murmur or signs of heart failure

Urgent investigations:

• ECG – Assess for ST changes, T wave inversions, or arrhythmias.
• Troponin – If acute coronary syndrome is suspected.
• Echocardiogram – If structural heart disease is suspected.
• Coronary CT angiography – If stable coronary artery disease is suspected.

If symptoms suggest unstable angina or myocardial infarction, urgent hospital transfer is required.

---

Q3: How would you manage James’ condition?

Lifestyle Modifications:

• Smoking cessation – Most effective intervention for reducing cardiovascular risk.
• Dietary changes – Reduce salt, saturated fats, processed foods; increase vegetables and whole grains.
• Exercise – Encourage 30 minutes of moderate-intensity exercise, 5 days per week.

Pharmacological Management:

• Aspirin 100mg daily – Prevents thrombotic events.
• Atorvastatin 40mg daily – Reduces LDL cholesterol.
• GTN spray (as-needed) – For symptom relief.
• Beta-blocker (e.g., metoprolol) or calcium channel blocker (e.g., amlodipine) – For angina control.
• ACE inhibitor (e.g., perindopril) – Indicated for hypertension and cardiovascular protection.

Follow-up Plan:

• Review in 2–4 weeks to assess symptom control and medication tolerance.
• Referral for exercise stress testing or coronary CT angiography if needed.

---

Q4: James is concerned about his risk of a heart attack. How would you counsel him?

1. Explain Cardiovascular Risk Assessment
   • “Your absolute cardiovascular risk is high due to multiple risk factors.”
   • “We use the Australian CVD Risk Calculator to estimate your 5-year risk of a heart attack or stroke.”
2. Address Modifiable Risk Factors
   • “Quitting smoking, improving diet, and taking prescribed medications can significantly lower your risk.”
3. Encourage Medication Adherence
   • “Medications like statins, aspirin, and antihypertensives are lifesaving, not just symptom-relieving.”
4. Provide Emotional Support and Follow-up
   • “We will monitor your progress and adjust your treatment plan as needed.”
   • “If you experience worsening symptoms, seek urgent medical attention.”

---

Q5: What preventive strategies can James implement to reduce his cardiovascular risk?

1. Lifestyle Changes:
   • Quit smoking – Seek support (e.g., nicotine replacement, Quitline).
   • Healthy diet – Increase fruit, vegetables, whole grains, and reduce processed foods and alcohol.
   • Regular exercise – 30 minutes of moderate-intensity activity most days.
2. Medication Adherence:
   • Take prescribed antihypertensives, statins, and aspirin as directed.
3. Regular Health Checks:
   • Monitor blood pressure, cholesterol, and diabetes risk annually.
   • Attend follow-up GP reviews to reassess risk and optimise treatment.
4. Know When to Seek Help:
   • Recognise early signs of worsening angina or heart failure.
   • Call 000 if symptoms suggest an acute cardiac event.

---

SUMMARY OF A COMPETENT ANSWER

• Systematic differential diagnosis, distinguishing cardiac from non-cardiac causes.
• Identification of red flags requiring urgent referral and further testing.
• Evidence-based management, including lifestyle changes, pharmacological therapy, and specialist referral if needed.
• Clear patient-centred counselling, addressing concerns about heart attack risk.
• Preventive strategies focusing on smoking cessation, diet, and medication adherence.

PITFALLS

• Failing to recognise unstable angina, delaying urgent referral.
• Overlooking red flags, missing acute coronary syndrome.
• Not calculating absolute cardiovascular risk, leading to suboptimal treatment decisions.
• Providing vague lifestyle advice, without clear, achievable goals.
• Lack of structured follow-up, risking poor long-term outcomes.

REFERENCES

• RACGP – RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• GP Exams – Cardiovascular disease NOS

---

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 Explains cardiovascular risk in a patient-centred manner.
1.2 Discusses lifestyle modifications and medication adherence.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including cardiac symptoms and risk factors.
2.2 Conducts an appropriate cardiovascular examination and interprets relevant investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Assesses cardiovascular risk using validated tools.
3.2 Differentiates between stable and high-risk cardiovascular conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan for cardiovascular disease.
4.2 Prescribes appropriate pharmacological therapy and lifestyle modifications.

5. Preventive and Population Health

5.1 Provides education on primary and secondary cardiovascular disease prevention.

6. Professionalism

6.1 Provides empathetic care while addressing the patient’s health concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Documents cardiovascular risk assessment and follows up appropriately.

9. Managing Uncertainty

9.1 Recognises when further investigations or specialist referral is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag symptoms requiring urgent intervention.

Competency at Fellowship Level

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