CCE-CE-029

Case ID: MI-003
Case Name: David Clarke
Age: 64
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes:

  • K75 (Acute Myocardial Infarction)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand concerns
1.2 Uses structured communication in an emergency
1.5 Provides clear instructions regarding urgent care
2. Clinical Information Gathering and Interpretation2.1 Takes a focused cardiovascular history
2.2 Identifies red flag symptoms of an MI
3. Diagnosis, Decision-Making and Reasoning3.1 Recognises an acute coronary syndrome (ACS) presentation
3.3 Prioritises differential diagnoses (MI vs non-cardiac causes)
4. Clinical Management and Therapeutic Reasoning4.2 Initiates emergency management
4.3 Facilitates immediate ambulance transfer
6. Professionalism6.2 Acts in the patient’s best interest despite reluctance
7. General Practice Systems and Regulatory Requirements7.2 Coordinates emergency care via ambulance and ED
8. Procedural Skills8.1 Recognises the need for immediate ECG, aspirin, and oxygen if required
9. Managing Uncertainty9.1 Balances risks and takes appropriate action despite diagnostic uncertainty
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises a life-threatening emergency requiring immediate intervention

CASE FEATURES

  • Middle-aged male presenting with chest pain concerning for myocardial infarction.
  • Urgent history-taking and decision-making required.
  • Management includes immediate stabilisation and emergency referral.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history
  2. Explain to the patient the most likely diagnosis
  3. Initiate immediate management
  4. Address any concerns the patient may have

SCENARIO

David Clarke, a 64-year-old man, presents to your general practice as a walk-in patient with severe central chest pain that started 20 minutes ago while he was walking his dog. He describes it as a crushing, pressure-like pain, radiating to his left shoulder and jaw. He is diaphoretic and nauseated and feels “like something is really wrong.”

On arrival, his vital signs are:

  • BP: 145/88 mmHg
  • HR: 96 bpm, regular
  • SpO2: 96% on room air
  • RR: 18 breaths/min
  • Temp: 36.6°C

PATIENT RECORD SUMMARY

Patient Details

Name: David Clarke
Age: 64
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None

Past History

  • No known medical conditions

Social History

  • Smoker: Nil
  • Alcohol: Occasional
  • Exercise: Walks daily

Family History

  • No known family history of heart disease

Vaccination and Preventative Activities

  • Influenza vaccine up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line

“Doctor, I’m really not feeling right. I’ve got this terrible crushing pain in my chest—it started about 20 minutes ago while I was walking my dog.”

General Information

(to be shared freely if the candidate asks general open-ended questions like “Tell me more about what’s happening.”)

  • The pain started suddenly while you were walking your dog in your local park.
  • You weren’t doing anything strenuous, just walking at a steady pace when you suddenly felt a tightness in your chest.
  • You describe the pain as “like someone is sitting on my chest”—a deep, crushing, pressure-like pain.
  • The pain has not gone away, and it is not getting better despite resting for 20 minutes.

Specific Information

(only revealed if the candidate asks relevant, targeted questions)

Background Information

  • You feel sweaty and a bit nauseous but haven’t vomited.
  • You feel short of breath, but you can still talk in full sentences.
  • You have never had pain like this before.

Pain Characteristics

  • Location: Central chest.
  • Quality: Crushing, pressure-like.
  • Radiation: Spreading to your left shoulder and jaw.
  • Severity: 8/10 (very painful but not the worst pain you’ve ever had).
  • Duration: Constant for 20 minutes.
  • Aggravating factors: The pain is not triggered by movement or deep breathing.
  • Relieving factors: Nothing makes it better—you have tried sitting and resting, but it’s still there.
  • Previous episodes: Never experienced anything like this before.

Associated Symptoms

  • Nausea and mild dizziness, but you haven’t vomited.
  • Clammy and sweaty but no fever or chills.
  • Mild shortness of breath—you can still talk in full sentences.
  • No cough, sore throat, or fever.
  • No recent illnesses.
  • No palpitations or skipped heartbeats.
  • No leg swelling or recent long travel.

Social and Emotional State

  • You are an independent, active person.
  • You usually walk every day, so this is unusual for you.
  • You live alone but have family in the area.
  • You are anxious but not panicking—you have a gut feeling something is wrong.
  • You are worried this might be serious, but you don’t want to overreact.

Emotional Reactions Based on the Candidate’s Approach

If the candidate explains that this could be a heart attack and you need urgent care:

  • You become more worried but still hesitant about calling an ambulance.
  • You might say:
    • “Are you sure? I don’t want to waste their time if this isn’t serious.”
    • “I don’t want to cause a fuss. Can’t I just wait a bit longer?”
  • If the candidate remains calm, firm, and reassuring, you eventually agree to emergency care.

If the candidate hesitates or does not strongly recommend emergency transfer:

  • You become more doubtful and may refuse to go to the hospital.
  • You might say:
    • “If you’re not sure, maybe I can just go home and rest.”
    • “I don’t think it’s that bad if you’re not insisting I go now.”

If the candidate reassures you but does not explain why urgent care is needed:

  • You remain reluctant and might suggest waiting it out:
    • “Let’s just see how I feel in an hour or two.”
    • “Maybe I can take some painkillers first?”

If the candidate calls an ambulance without explaining the urgency:

  • You feel frustrated and confused, saying:
    • “Why are you calling an ambulance? You haven’t even told me what’s going on!”

If the candidate provides a clear and structured explanation about a possible heart attack and the risks of delaying care:

  • You begin to accept the seriousness and may say:
    • “I didn’t realise a heart attack could feel like this. I thought it would be more dramatic.”
    • “So you think this could be my heart? I guess I should go to the hospital then.”

Reluctance and Common Patient Concerns

(Ask these questions naturally during the encounter)

  • “Are you sure this isn’t just indigestion?”
  • “I feel okay apart from the pain—do I really need to go to the hospital?”
  • “Can you just give me something for the pain instead?”
  • “If I go to hospital, how long will I have to stay?”
  • “I have an important meeting later today—do you think I can just wait a bit?”
  • “Will I need surgery? My father had heart problems and ended up needing surgery.”

Final Outcome

If the candidate does well

(explains clearly and reassures appropriately):

  • You agree to the ambulance transfer and say:
    • “Okay, if you think this is serious, I’ll go to the hospital.”
    • “I trust you. I don’t want to take any risks if this could be my heart.”

If the candidate does not clearly communicate the urgency:

  • You hesitate, delay, or refuse transfer, saying:
    • “I think I’ll just go home and rest first. I’ll come back if it gets worse.”
    • “It doesn’t seem bad enough for an ambulance. I’ll drive myself later.”

If the candidate strongly insists but doesn’t explain the rationale:

  • You reluctantly agree but remain sceptical.

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on the characteristics of the chest pain and associated symptoms.

The competent candidate should:

  • Obtain a detailed history of the chest pain, including:
    • Site: Central chest
    • Character: Crushing, pressure-like
    • Radiation: Left shoulder and jaw
    • Onset: Sudden onset 20 minutes ago while walking
    • Duration: Continuous since onset
    • Time Intensity: Continuous getting worse
    • Exacerbating/Relieving factors: No relief with rest or change in position
    • Associated: sweating
    • Severity: 8/10
  • Exclude non-cardiac causes (pleuritic pain, pain with movement, recent illness).
  • Explore past medical history, including any prior cardiac events.
  • Ask about medications and allergies.
  • Clarify family history of heart disease.
  • Assess the patient’s concerns and expectations.

Task 2: Explain to the patient the most likely diagnosis and the need for urgent medical attention.

The competent candidate should:

  • Clearly communicate that the symptoms are highly suggestive of an acute coronary syndrome (ACS), likely an ST-elevation myocardial infarction (STEMI) or non-STEMI.
  • Explain that MI can present without severe distress and that delaying care increases the risk of complications.
  • Emphasise that urgent hospital transfer is critical, as early intervention (e.g., thrombolysis or percutaneous coronary intervention) reduces mortality and morbidity.
  • Address concerns about “waiting it out” by explaining that cardiac events can worsen unpredictably.
  • Use simple, non-alarmist language while reinforcing the need for immediate treatment.

Task 3: Initiate immediate management, including any necessary medications and arrangements for emergency transfer.

The competent candidate should:

  • Call an ambulance immediately for transfer to a hospital with cardiac services.
  • Administer aspirin (300 mg, chewed) unless contraindicated.
  • Consider glyceryl trinitrate (GTN) sublingual spray (unless hypotensive).
  • Monitor vital signs for deterioration while awaiting transfer.
  • Avoid unnecessary delays—do not wait for investigations such as an ECG in a general practice setting.
  • Provide reassurance and continuous monitoring while awaiting ambulance arrival.

Task 4: Address any concerns the patient may have while ensuring timely intervention.

The competent candidate should:

  • Respond empathetically and confidently to concerns.
  • Reassure that hospital treatment is essential, even if symptoms improve.
  • Address fear of hospitalisation or unnecessary intervention.
  • Encourage cooperation by explaining potential life-threatening risks of delaying care.
  • Provide clear next steps so the patient understands what will happen at the hospital.

SUMMARY OF A COMPETENT ANSWER

  • Structured history-taking, covering pain characteristics, associated symptoms, and risk factors.
  • Effective communication of the urgency of the situation in a clear, reassuring, and non-alarmist manner.
  • Immediate initiation of emergency management (aspirin, GTN if appropriate, ambulance transfer).
  • Confidently addresses patient reluctance while ensuring timely intervention.
  • Avoids delays in definitive care, ensuring appropriate triage and handover to emergency services.

PITFALLS

  • Failing to recognise the urgency of the presentation and not calling an ambulance immediately.
  • Delaying referral by performing unnecessary investigations (e.g., waiting for ECG results before calling an ambulance).
  • Minimising symptoms and failing to address patient reluctance effectively.
  • Not administering first-line treatments (aspirin, GTN if indicated).
  • Using overly complex or alarmist language, increasing patient anxiety instead of reassuring them.
  • Focusing on risk factor management instead of acute care—this is an emergency situation.

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

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.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused cardiovascular history.
2.2 Identifies red flag symptoms of an MI.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises an acute coronary syndrome (ACS) presentation.
3.3 Prioritises differential diagnoses (MI vs non-cardiac causes).

4. Clinical Management and Therapeutic Reasoning

4.2 Initiates emergency management.
4.3 Facilitates immediate ambulance transfer.

6. Professionalism

6.2 Acts in the patient’s best interest despite reluctance.

7. General Practice Systems and Regulatory Requirements

7.2 Coordinates emergency care via ambulance and ED.

8. Procedural Skills

8.1 Recognises the need for immediate ECG, aspirin, and oxygen if required.

9. Managing Uncertainty

9.1 Balances risks and takes appropriate action despite diagnostic uncertainty.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises a life-threatening emergency requiring immediate intervention.

Competency at Fellowship Level

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