CCE-CE-058.1

CASE INFORMATION

Case ID: CCE-CV-018
Case Name: John Matthews
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K77 – Heart Failure

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages the patient
1.2 Explores the patient’s concerns, ideas, and expectations
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation2.1 Takes a structured history, including symptoms, functional limitations, and exacerbating factors
2.2 Identifies red flags for decompensated heart failure (e.g., worsening breathlessness, orthopnoea, fluid overload)
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between heart failure with preserved and reduced ejection fraction
3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning4.1 Provides evidence-based pharmacological and non-pharmacological management
4.2 Implements strategies to optimise fluid balance, symptom control, and functional capacity
5. Preventive and Population Health5.1 Identifies and manages cardiovascular risk factors (e.g., hypertension, diabetes)
5.2 Encourages lifestyle modifications to prevent disease progression
6. Professionalism6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate medication monitoring, referral pathways, and chronic disease management planning
8. Procedural Skills8.1 Orders and interprets relevant investigations, such as echocardiogram, BNP, renal function, and chest X-ray
9. Managing Uncertainty9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies and appropriately manages acute decompensated heart failure

CASE FEATURES

  • Need for optimisation of heart failure management, fluid control, and lifestyle interventions
  • Progressive breathlessness, fatigue, and ankle swelling over several months
  • Concerns about reduced exercise capacity and need for medication changes
  • History of hypertension and previous myocardial infarction

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, including symptom onset, functional limitations, exacerbating factors, and impact on daily life.
  2. Identify red flags for decompensated heart failure and assess for contributing factors.
  3. Provide a diagnosis and discuss an initial management plan.
  4. Educate the patient on fluid and salt restriction, medication adherence, and when to seek urgent care.

SCENARIO

John Matthews, a 72-year-old retired mechanic, presents with increasing breathlessness, fatigue, and swollen ankles over the past four months. He struggles to walk more than 100 metres without needing to rest and has been sleeping with two pillows to breathe better at night.

He has a history of hypertension and a myocardial infarction five years ago. He is worried about his worsening symptoms and asks whether he needs new medications or stronger treatment.

His main concerns are:

  • “Why am I getting more breathless?”
  • “Is my heart getting worse?”
  • “Do I need to change my medications?”
  • “What can I do to stop this from getting worse?”

PATIENT RECORD SUMMARY

Patient Details

Name: John Matthews
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • None known

Medications

  • Perindopril 5mg daily (for hypertension)
  • Aspirin 100mg daily (post-MI)
  • Atorvastatin 40mg daily (hyperlipidaemia)
  • Frusemide 20mg PRN (fluid retention)

Past History

  • Hypertension
  • Myocardial infarction (5 years ago)
  • Hyperlipidaemia
  • Mild chronic kidney disease (eGFR 55 mL/min)

Social History

  • Lives with his wife, who helps with shopping and household chores
  • Ex-smoker, quit 10 years ago after smoking for 30 years
  • Drinks 2–3 beers on weekends
  • Struggles with salt restriction, enjoys processed and takeaway foods
  • Limited exercise due to breathlessness

Family History

  • Father had heart failure in his 70s
  • Mother had type 2 diabetes

Vaccination and Preventative Activities

No recent echocardiogram or BNP testing

  • Up to date with vaccinations

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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I feel like I’m slowing down. I get out of breath so easily now, and my ankles keep swelling up. Is my heart getting worse?”

General Information

John Matthews is a 72-year-old retired mechanic presenting with increasing breathlessness, fatigue, and ankle swelling over the past four months.

  • He first noticed breathlessness about four months ago, and it has been gradually getting worse.
  • He used to walk to the local shops without a problem, but now he struggles to walk more than 100 metres without stopping.
  • He sleeps with two pillows to help with his breathing and occasionally wakes up short of breath at night.
  • His ankles have been swelling, especially by the evening, and his shoes feel tighter than usual.
  • He feels more tired than before, needing to rest frequently during the day.

His main concerns are:

  • “Why am I getting more breathless?”
  • “Is my heart getting worse?”
  • “Do I need to change my medications?”
  • “What can I do to stop this from getting worse?”

Specific Information (To be revealed only when asked)

Symptoms and Functional Limitations

  • Breathlessness on exertion, worsening over months.
  • Sleeping with two pillows, but occasionally wakes up short of breath.
  • No chest pain, palpitations, dizziness, or fainting.
  • Feels bloated and full after meals, but no major appetite loss.
  • Gained about 3 kg in the past few months.

Fluid Retention and Swelling

  • Noticed ankle swelling worsening towards the evening, but improves somewhat overnight.
  • Has skipped frusemide some days because he “felt okay”.
  • No severe leg pain or redness.

Triggers and Lifestyle Factors

  • Diet includes salty and processed foods, enjoys takeaway meals 2–3 times a week.
  • Drinks 2–3 beers on weekends, unsure if this is affecting his heart.
  • Has been avoiding physical activity due to fatigue.
  • Occasionally forgets to take frusemide but takes other medications regularly.

Concerns About Heart Function

  • Worried that his heart failure is getting worse, especially because his father had heart failure.
  • Wants to know if stronger medications or new treatments are needed.
  • Unsure if he will need hospital admission.

Impact on Daily Life

  • Finds it difficult to manage household chores.
  • Wife has been helping more, but he worries about burdening her.
  • Avoids social outings due to fatigue and breathlessness.

Emotional Cues

John is concerned but hopeful for solutions.

  • Frustrated with worsening breathlessness: “I used to be able to do more, but now I feel weak all the time.”
  • Worried about disease progression: “Am I going to end up in hospital?”
  • Seeking reassurance: “Can I do anything to stop this from getting worse?”

If the candidate provides a clear management plan, John will be reassured and motivated to adjust his lifestyle.

If the candidate is vague or dismissive, John may become anxious about his long-term prognosis.

Questions for the Candidate

John will ask some of the following questions, especially if the doctor does not address them directly:

  1. “Why am I getting more breathless?”
  2. “Is my heart getting worse?”
  3. “Do I need stronger medications?”
  4. “Should I be worried about going to hospital?”
  5. “What can I do to help my heart?”
  6. “Can I still have a few beers on the weekend?”
  7. “Will I have to change my diet?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

  • John will feel reassured and motivated to follow medical advice.
  • He will accept medication adjustments and lifestyle changes.
  • He may say, “I’ll try to watch my salt and keep my fluid levels stable.”

If the candidate is vague or dismissive:

  • John may insist on seeing a specialist or request unnecessary tests.
  • He may say, “So, am I just supposed to wait until I get worse?”

Key Takeaways for the Candidate

  • Take a structured heart failure history, assessing symptom progression, functional status, and risk factors.
  • Optimise heart failure management, including medications, fluid control, and dietary modifications.
  • Explain red flags and when to seek medical attention.
  • Ensure follow-up to reassess symptoms and adjust treatment if needed.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including symptom onset, functional limitations, exacerbating factors, and impact on daily life.

The competent candidate should:

  • Elicit a structured history of heart failure symptoms, including:
    • Progressive dyspnoea (on exertion and at rest).
    • Orthopnoea (difficulty lying flat).
    • Paroxysmal nocturnal dyspnoea (PND).
    • Peripheral oedema and weight gain.
    • Fatigue and reduced exercise tolerance.
  • Assess impact on daily life, including ability to perform daily activities and effect on social life.
  • Identify exacerbating factors, such as:
    • Dietary excess (salt intake, alcohol use).
    • Poor medication adherence (frusemide non-compliance).
    • Infections or other comorbid conditions.

Task 2: Identify red flags for decompensated heart failure and assess for contributing factors.

The competent candidate should:

  • Recognise red flags for decompensated heart failure, including:
    • Rapid weight gain (>2kg in a few days).
    • Marked worsening of dyspnoea or orthopnoea.
    • Significant peripheral oedema and ascites.
    • Signs of pulmonary congestion (wheeze, crackles, raised JVP).
    • Confusion, hypotension, worsening renal function.
  • Assess for common triggers, including:
    • Poor adherence to medications or diet.
    • New ischaemic event (angina, recent MI).
    • Arrhythmias (AF, ventricular tachycardia).
    • Respiratory infections or worsening renal function.

Task 3: Provide a diagnosis and discuss an initial management plan.

The competent candidate should:

  • Explain the likely diagnosis:
    • Worsening chronic heart failure, likely due to fluid overload.
    • No immediate signs of acute decompensation but at risk.
  • Optimise pharmacological management:
    • Increase frusemide dose or ensure adherence.
    • Consider adding spironolactone if oedema persists.
    • Review ACE inhibitors and beta-blockers for titration.
    • Monitor renal function and electrolytes.
  • Encourage dietary and lifestyle modifications:
    • Reduce salt intake and fluid restriction if needed.
    • Encourage gentle physical activity.

Task 4: Educate the patient on fluid and salt restriction, medication adherence, and when to seek urgent care.

The competent candidate should:

  • Provide self-monitoring strategies:
    • Daily weight monitoring to detect early fluid retention.
    • Avoid excessive fluid intake (>1.5L/day if fluid overload present).
    • Reduce processed and salty foods.
  • Emphasise medication adherence:
    • Regular frusemide use to manage fluid balance.
    • Ensure patient understands their medication regimen.
  • Explain warning signs that require urgent review:
    • Worsening breathlessness, persistent cough, severe oedema, dizziness, chest pain.
  • Arrange follow-up in one to two weeks to reassess symptoms and medication response.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, identifying symptom progression, functional status, and exacerbating factors.
  • Recognises red flags for decompensated heart failure and ensures timely intervention.
  • Provides evidence-based management, including medication optimisation, dietary changes, and fluid restriction.
  • Educates the patient on self-monitoring and when to seek medical help.
  • Plans for close follow-up to reassess progress and adjust treatment.

PITFALLS

  • Failing to identify worsening fluid overload, leading to delayed escalation of treatment.
  • Not considering medication non-adherence, missing an opportunity to optimise management.
  • Overlooking dietary factors, which may be contributing to worsening symptoms.
  • Not recognising the need for timely follow-up, risking further decompensation.
  • Failing to provide clear safety-netting advice, leading to delayed presentation in case of deterioration.

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.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including symptom onset, functional limitations, and exacerbating factors.
2.2 Identifies red flags for decompensated heart failure (e.g., worsening breathlessness, orthopnoea, fluid overload).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between heart failure with preserved and reduced ejection fraction.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based pharmacological and non-pharmacological management.
4.2 Implements strategies to optimise fluid balance, symptom control, and functional capacity.

5. Preventive and Population Health

5.1 Identifies and manages cardiovascular risk factors (e.g., hypertension, diabetes).
5.2 Encourages lifestyle modifications to prevent disease progression.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate medication monitoring, referral pathways, and chronic disease management planning.

8. Procedural Skills

8.1 Orders and interprets relevant investigations, such as echocardiogram, BNP, renal function, and chest X-ray.

9. Managing Uncertainty

9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages acute decompensated heart failure.

Competency at Fellowship Level

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