CCE-CBD-153

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you interpret David’s blood test results?

• Prompt: Discuss prediabetes criteria and cardiovascular risk implications
• Prompt: Explain lipid profile findings and need for further intervention

Q2. What would be your immediate management plan for David?

• Prompt: Lifestyle advice targeting diet, exercise, and weight
• Prompt: Discuss medication optimisation and referrals

Q3. How would you assess David’s absolute cardiovascular risk?

• Prompt: Describe use of risk calculators and how to communicate risk
• Prompt: Include considerations for Indigenous vs non-Indigenous Australians

Q4. What follow-up tests and monitoring would you recommend?

• Prompt: Timeframes for repeat HbA1c, fasting glucose
• Prompt: Additional tests (e.g., liver function, microalbuminuria)

Q5. How would you engage David in shared decision-making to address his risk factors?

• Prompt: Explore his values and readiness for change
• Prompt: Discuss options such as health coaching, dietitian, and exercise physiology referral

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you interpret David’s blood test results?

Answer:

David’s blood test results show several abnormalities which require clinical interpretation and communication:

Prediabetes:

• His fasting blood glucose is 6.2 mmol/L, which is above the normal range (3.9-5.5 mmol/L) but below the threshold for diabetes diagnosis (>7.0 mmol/L).
• His HbA1c is 6.1% (43 mmol/mol), indicating impaired glucose tolerance/prediabetes, as per NHMRC guidelines (HbA1c 5.7%-6.4%).

Lipid Profile:

• Total cholesterol is 5.8 mmol/L, slightly above target (<5.5 mmol/L).
• LDL cholesterol is 3.8 mmol/L, which is above the target (<2.5 mmol/L for moderate risk; <1.8 mmol/L for high risk individuals as per National Vascular Disease Prevention Alliance guidelines).
• HDL is 0.9 mmol/L, which is low (<1.0 mmol/L).
• Triglycerides are elevated at 2.3 mmol/L (normal <1.7 mmol/L).

Thyroid Function:

• TSH is 3.5 mIU/L, within the upper normal limit, but not suggestive of hypothyroidism as Free T4 is normal at 14 pmol/L.

Risk Summary:

• David is classified as prediabetic and has dyslipidaemia that increases his absolute cardiovascular risk.
• He has modifiable risk factors, including obesity (BMI 31), sedentary lifestyle, and a family history of diabetes and cardiovascular disease.

A clear explanation in non-technical language should be provided, addressing his concerns about diabetes and outlining how these numbers reflect his current health status and risks.

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Q2: What would be your immediate management plan for David?

Answer:

David requires a comprehensive, multifaceted management approach, focusing on lifestyle modification and optimising pharmacotherapy.

Lifestyle Interventions:

• Weight management: Encourage a gradual weight loss of 5-10%, which can improve insulin sensitivity and lipid profiles.
• Dietary advice: Referral to a dietitian to implement a Mediterranean diet or low glycaemic index plan, reducing saturated fats and increasing fibre.
• Physical activity: Recommend at least 150 minutes of moderate-intensity aerobic exercise per week, with resistance training twice weekly (per Australian guidelines).

Pharmacological Management:

• Review and optimise lipid-lowering therapy. Consider increasing atorvastatin dose or switching to a more potent statin to reach LDL goals (<2.5 mmol/L, or <1.8 mmol/L if high risk).
• Discuss possible initiation of metformin if lifestyle changes are insufficient over 3-6 months, given his prediabetes and obesity, following RACGP guidelines.

Other Considerations:

• Screen for microalbuminuria to assess for early nephropathy.
• Blood pressure is currently borderline; monitor closely and reinforce sodium restriction.

Provide written resources, set SMART goals, and schedule regular reviews to assess progress.

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Q3: How would you assess David’s absolute cardiovascular risk?

Answer:

David’s absolute cardiovascular risk should be assessed using the Australian Absolute CVD Risk Calculator, based on the Framingham equation, incorporating:

• Age, gender, systolic BP, total and HDL cholesterol, smoking status, diabetes status, and treatment factors.

Current status:

• Non-smoker, BP 138/85 mmHg, total cholesterol 5.8, HDL 0.9.
• Prediabetes, not yet diabetes.

His calculated 5-year absolute CVD risk is likely in the moderate to high range (10-15%), but factors such as family history and low HDL may push this higher.

If he were Aboriginal or Torres Strait Islander and over 35, he would require earlier and more aggressive screening.

Communicate risk effectively by using absolute risk charts and visual aids, framing the discussion around modifiable factors.

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Q4: What follow-up tests and monitoring would you recommend?

Answer:

Short-Term Monitoring:

• HbA1c and fasting glucose: Repeat in 3 months to assess progression or improvement.
• Lipid profile: Recheck in 6-12 weeks after lifestyle changes and/or medication adjustment.
• Blood pressure: Monitor at each visit, at least every 3 months.

Additional Investigations:

• Urine albumin-creatinine ratio (ACR) to assess for nephropathy.
• Liver function tests (LFTs), considering statin therapy adjustment.
• ECG: Optional, if there are cardiovascular symptoms or high CVD risk.
• Consider fundoscopy and neurological assessment for complications if diabetes progresses.

Establish a recall system and coordinate team care (nurse, dietitian, exercise physiologist).

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Q5: How would you engage David in shared decision-making to address his risk factors?

Answer:

Build Rapport and Explore Beliefs:

• Acknowledge his concerns about diabetes and heart disease.
• Explore his readiness for change (e.g., motivational interviewing).

Present Options Clearly:

• Explain the benefits and risks of lifestyle interventions and medications in a clear and respectful manner.
• Provide written materials and decision aids to support understanding.

Collaborative Goal-Setting:

• Set achievable short-term goals, such as 5 kg weight loss over 3 months, or increasing daily steps.
• Discuss referral options, like a dietitian, exercise physiologist, or health coach.

Follow-Up Plan:

• Arrange review appointments and ongoing encouragement.
• Empower David to take an active role, reinforcing that small changes have significant health impacts.

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SUMMARY OF A COMPETENT ANSWER

• Interprets prediabetes and dyslipidaemia accurately with reference to Australian guidelines.
• Develops a comprehensive lifestyle and medication management plan.
• Assesses and communicates absolute cardiovascular risk effectively.
• Plans appropriate monitoring and follow-up including additional investigations.
• Demonstrates shared decision-making and motivational interviewing techniques.

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PITFALLS

• Failing to recognise prediabetes and the need for early intervention.
• Not assessing absolute CVD risk systematically.
• Overlooking the need for multidisciplinary care and patient education.
• Not considering patient values, resulting in poor engagement.
• Inadequate follow-up and monitoring for progression to diabetes.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (“Red Book”)
• NHMRC National Evidence-Based Guideline for Diagnosis, Prevention and Management of Type 2 Diabetes
• National Vascular Disease Prevention Alliance
• Australian Government Department of Health on Absolute CVD Risk Guidelines

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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 Demonstrates diagnostic reasoning to arrive at a rational diagnosis.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes and monitors therapies appropriately.

5. Preventive and Population Health

5.1 Provides counselling on modifiable risk factors and behaviours.

6. Professionalism

6.1 Maintains ethical practice and confidentiality.
6.2 Provides culturally safe care.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care effectively, including referrals and use of local resources.

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 severe acute and chronic health conditions.

Competency at Fellowship Level

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