CCE-CBD-149.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis, and how would you prioritise them?

A competent candidate would approach this systematically, prioritising life-threatening conditions first.

Primary Differential Diagnoses:

• Acute Coronary Syndrome (ACS):
  • Classic exertional chest pain relieved by rest.
  • Radiation to jaw, SOB on exertion, family history of early cardiac death.
  • Non-specific ECG changes raise concern.
• Stable Angina Pectoris:
  • Pain predictable on exertion, relieved by rest.
  • Fits the pattern of stable angina but requires exclusion of ACS.
• Gastro-oesophageal Reflux Disease (GORD):
  • Less likely given exertional nature but can mimic cardiac pain.
• Musculoskeletal chest wall pain (Costochondritis):
  • Unlikely without reproducible tenderness and relation to movement.
• Pulmonary embolism (PE):
  • Considered due to rural immobility, but lacks tachycardia, pleuritic pain, or haemoptysis.

Prioritisation:

1. ACS (Unstable Angina/NSTEMI):
   • Potentially life-threatening. Needs urgent exclusion.
2. Stable Angina:
   • Likely given the exertion-rest pattern but still concerning.
3. GORD/Costochondritis:
   • Lower likelihood but considered after ruling out cardiac causes.

Clinical Reasoning:
Given the family history, risk factors (smoking, hypertension, hyperlipidaemia), and exertional pattern, ACS must be ruled out first.

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Q2: What is your immediate management plan in this rural setting?

Immediate Actions:

• Emergency transfer to ED:
  • Arrange urgent transfer to the nearest hospital with cardiac services (via ambulance if unstable).
• While awaiting transfer:
  • Administer sublingual GTN for symptom relief.
  • Aspirin 300 mg chewed and swallowed.
  • Oxygen therapy if SpO2 < 94% (currently not needed).
  • Consider clopidogrel 300 mg if ACS suspected and transport time significant (per local guidelines).
  • Continuous ECG monitoring.
• Pain management:
  • GTN as above, cautious of hypotension.
• Communication:
  • Notify hospital of incoming potential ACS.
  • Maintain communication with paramedics.

Clinical Reasoning:
Limited resources in rural practice mean stabilisation is critical while arranging urgent transport.

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Q3: What ongoing management strategies will you discuss with Michael for his cardiovascular risk factors?

Lifestyle Modifications:

• Smoking cessation: Offer NRT, varenicline/bupropion, refer to Quitline.
• Dietary changes: Low-fat, Mediterranean diet.
• Physical activity: Gradual, supervised exercise post-cardiac evaluation.
• Weight reduction: Target BMI < 25.

Pharmacological:

• Antihypertensives: Optimise BP control (goal < 130/80 mmHg).
• Statins: Continue atorvastatin, consider increasing dose post-cardiac review.
• Antiplatelet therapy: Long-term if ACS confirmed.

Monitoring:

• Regular review of lipids, BP, and HbA1c (screen for diabetes).
• Cardiac rehabilitation post-event.
• Annual health assessments.

Referral:

• Cardiology for further evaluation (stress testing/angiography).

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Q4: How would you address Michael’s concerns regarding his risk and access to emergency services?

Acknowledge Concerns:

• Empathise with anxiety around his father’s death and rural isolation.

Education:

• Explain the symptoms of angina and myocardial infarction.
• Educate on when to seek urgent help.
• Provide an action plan, including calling 000 immediately with chest pain.

Rural Specifics:

• Provide education on remote monitoring apps if feasible.
• Encourage family involvement in emergency response planning.

Follow-Up:

• Ensure regular reviews and reinforce emergency plans.

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Q5: What preventive health activities should be updated or initiated?

Cancer Screening:

• Bowel cancer screening: Encourage participation (National Bowel Cancer Screening Program).
• Prostate screening: Discuss PSA testing (informed decision-making).

Vaccinations:

• Ensure annual influenza and COVID-19 boosters.
• Pneumococcal vaccine reviewed (completed, booster if indicated).

Chronic Disease Prevention:

• Diabetes screening: Given family history and risk factors (fasting glucose/HbA1c).
• Osteoporosis risk assessment: Based on age, smoking history.

Lifestyle Support:

• Smoking cessation counselling.
• Alcohol intake within guidelines.

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SUMMARY OF A COMPETENT ANSWER

• Prioritises ACS and initiates urgent management in a rural setting.
• Demonstrates comprehensive cardiovascular risk management.
• Incorporates patient education and rural health system navigation.
• Covers preventive health in line with Australian guidelines.

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PITFALLS

• Failure to recognise ACS as a life-threatening emergency.
• Inadequate pain and symptom management while awaiting transfer.
• Neglecting preventive care such as cancer screening.
• Lack of clear communication and safety netting, especially in rural context.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Australian Clinical Guidelines for Management of Acute Coronary Syndromes
• Cardiac Rehabilitation in Rural and Remote Areas

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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, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.
3.2 Selects appropriate options for investigation and management.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Provides appropriate advice and support.

5. Preventive and Population Health

5.1 Provides counselling on modifiable risk factors.
5.2 Provides appropriate screening and preventive care.

6. Professionalism

6.1 Adheres to relevant codes and standards.
6.2 Maintains appropriate professional boundaries.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care effectively.
7.2 Uses resources effectively and appropriately.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty and patient expectations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages significant and potentially life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Provides appropriate care and coordination in a rural context.

Competency at Fellowship Level

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