CASE INFORMATION

Case ID: CCE-2025-06
Case Name: David Thompson
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K01 (Chest Pain, NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages with the patient empathetically. 1.2 Uses clear, patient-centred language to explore symptoms and concerns. 1.4 Elicits the patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured chest pain history, identifying red flags. 2.2 Assesses cardiac vs. non-cardiac causes of chest pain. 2.3 Identifies risk factors for acute coronary syndrome (ACS).
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between cardiac, musculoskeletal, gastrointestinal, and pulmonary causes of chest pain. 3.3 Determines the need for urgent referral or hospitalisation.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate acute and long-term management plan. 4.3 Provides patient-centred education on risk factor modification. 4.5 Recognises when urgent escalation to emergency services is required.
5. Preventive and Population Health	5.2 Discusses cardiovascular risk reduction strategies.
6. Professionalism	6.1 Ensures empathetic and non-judgemental communication.
7. General Practice Systems and Regulatory Requirements	7.2 Understands appropriate referral pathways for suspected ACS.
9. Managing Uncertainty	9.1 Recognises when investigation vs. reassurance is required.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises life-threatening chest pain causes requiring urgent intervention (e.g., ACS, pulmonary embolism, aortic dissection).

CASE FEATURES

Middle-aged man presenting with chest pain of uncertain cause.
Distinguishing between cardiac and non-cardiac causes (musculoskeletal, reflux, anxiety, pulmonary).
Urgency assessment—does this patient need immediate hospital referral?
Addressing patient anxiety about a heart attack.
Preventive care and risk factor modification.

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:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

David Thompson, a 58-year-old school principal, presents to your clinic with intermittent chest discomfort over the past three weeks. He describes the pain as a tightness across his chest, sometimes radiating to his left arm. It usually occurs when he is walking up stairs and resolves within 5–10 minutes of rest.

He is concerned that he might have heart disease, as his father had a heart attack at 60.

PATIENT RECORD SUMMARY

Patient Details

Name: David Thompson
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Atorvastatin 20 mg OD (for hyperlipidaemia)
Perindopril 5 mg OD (for hypertension)

Past History

Hypertension (diagnosed 5 years ago, well controlled)
Hyperlipidaemia (diagnosed 3 years ago, on statin therapy)
No previous cardiac events

Family History

Father had an MI at 60
Mother had type 2 diabetes

Smoking and Alcohol

Ex-smoker (quit 15 years ago, 20-pack-year history)
Drinks 2–3 standard drinks per week

Vaccination and Preventative Activities

Routine vaccinations 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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I’ve been getting this tight feeling in my chest on and off for the last few weeks. It goes away when I rest, but I’m worried it could be something serious.”

General Information

You are David Thompson, a 58-year-old school principal. Over the past three weeks, you have noticed a tight feeling in your chest that comes and goes. It happens mostly when you are walking upstairs or carrying heavy things, and it spreads to your left arm sometimes. It lasts for about 5 to 10 minutes and eases when you rest. You haven’t had anything like this before, and it’s starting to make you nervous.

Specific Information

(Revealed When Asked)

Background Information

You decided to come in because your father had a heart attack at 60, and you’re worried this could be a warning sign. You don’t want to ignore it if it’s something serious, but you also don’t want to overreact if it’s nothing.

You do not have:

Sudden, severe pain that comes on at rest.
Sweating, nausea, dizziness, or feeling faint.
Palpitations or irregular heartbeat.
Cough, fever, or recent illness.

You have never had a heart problem before, and you try to stay active, but lately, you’ve felt more tired than usual.

Pain Characteristics:

The pain feels like a tightness or pressure in your chest, not sharp or stabbing.
It is worse with exertion and relieved by rest.
The discomfort spreads to your left arm sometimes, but not to your jaw or back.
It is not affected by deep breathing or movement.
It does not feel like heartburn, and eating doesn’t seem to change it.

Cardiovascular Risk Factors:

Hypertension and high cholesterol, both on medication.
Ex-smoker (20-pack-year history, quit 15 years ago).
Family history of coronary artery disease—your father had a heart attack at 60.
Moderate alcohol intake (2–3 drinks per week).
No history of diabetes.

Other Symptoms and Psychosocial Factors:

You feel more tired than usual, but you put it down to stress at work.
You have been under some work pressure, but you wouldn’t say you feel anxious.
You are worried about how this might impact your ability to keep up with your usual activities.

Emotional Cues and Body Language

Concerned but composed—you know this could be serious but hope it’s not.
You become more anxious if the doctor mentions heart problems, especially if they suggest urgent tests.
Reassured if the doctor explains things clearly, but you will still ask, “So how do we rule out a heart problem?”
If the doctor brushes it off as stress, you will feel frustrated and say, “But this doesn’t feel like stress. Shouldn’t we check my heart?”

Patient Concerns and Questions

1. “Could this be a heart attack waiting to happen?”

You are looking for a straightforward but reassuring answer.
If the doctor says “It’s unlikely,” you will ask, “Then why is it happening?”

2. “Do I need to go to hospital?”

You don’t want to go unnecessarily, but you don’t want to take a risk either.
If the doctor recommends it, you will ask, “Can this wait, or do I need to go today?”

3. “What tests do I need?”

You are expecting an ECG and possibly a stress test.
If the doctor doesn’t suggest testing, you will ask, “But how can we be sure it’s not my heart?”

4. “What can I do to stop this from getting worse?”

You are willing to make changes if needed.
You will ask about exercise, diet, and medications.

5. “If this isn’t my heart, what else could it be?”

You want to know if this could be muscular, reflux, or something else.
If the doctor suggests stress or anxiety, you will ask, “But why does it only happen when I exercise?”

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and explains things well:

You feel calmer and are happy to follow the plan.
You agree to tests if recommended, and you feel less worried.

If the doctor is vague or dismisses your concerns:

You will push for urgent tests or ask for a second opinion.
You might say, “I’d rather check this properly than wait until it’s too late.”

If the doctor recommends immediate hospitalisation:

You will hesitate and ask, “Do I really need to go right now?”
If they explain why it’s urgent, you will agree.

If the doctor says it might be stress-related:

You will say, “I don’t feel that stressed. Couldn’t this be my heart?”

Your Expectations from This Consultation

You want a clear explanation of what this could be—is it serious or not?
You need to know what tests are necessary and whether this requires hospitalisation.
You want practical advice on managing this and preventing it from getting worse.
You don’t want to be dismissed, but you also don’t want unnecessary treatment.

End of Consultation Cues

If the doctor provides clear reassurance and a plan, you will feel more at ease.
If the doctor dismisses your concerns, you will insist on further testing.
If the doctor explains everything properly, you will trust their judgment and follow the recommended steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including pain characteristics, risk factors, and concerns.

The competent candidate should:

Elicit a structured history of the chest pain, including:
- Onset, duration, and frequency (acute vs. chronic, exertional vs. resting).
- Location and radiation (central, left-sided, referred to arm, jaw, back).
- Nature of pain (tightness, pressure, sharp, burning).
- Aggravating and relieving factors (exertion, rest, breathing, posture, food intake).
- Associated symptoms (shortness of breath, diaphoresis, palpitations, dizziness, nausea).
Assess cardiovascular risk factors, including:
- Hypertension, hyperlipidaemia, diabetes, smoking history, family history of ischaemic heart disease (IHD).
Explore patient concerns and expectations, including:
- “What are you worried this might be?”
- “Do you think this could be a heart attack?”
- “What would you like to get out of today’s visit?”

Task 2: Formulate a differential diagnosis, distinguishing between cardiac, musculoskeletal, gastrointestinal, and other causes.

The competent candidate should:

Differentiate between serious and benign causes of chest pain:
- Cardiac:
  - Stable angina – exertional, relieved by rest.
  - Acute coronary syndrome (ACS) – prolonged, worsening pain, associated symptoms.
  - Pericarditis – sharp pain, worse with inspiration, relieved by sitting forward.
- Pulmonary:
  - Pulmonary embolism (PE) – pleuritic pain, tachycardia, dyspnoea, risk factors.
  - Pneumothorax – sudden onset, young/smoker, absent breath sounds.
- Gastrointestinal:
  - Gastro-oesophageal reflux disease (GORD) – burning pain, postprandial, relieved by antacids.
  - Oesophageal spasm – intermittent, relieved by GTN.
- Musculoskeletal:
  - Costochondritis – localised, tender to palpation, no exertional component.
  - Muscle strain – recent activity, reproducible pain.
Determine urgency for referral or further investigation based on symptoms.

Task 3: Explain the likely diagnosis to the patient, addressing concerns empathetically.

The competent candidate should:

Acknowledge patient concerns:
- “I understand that chest pain can be alarming, and it’s important that we investigate it properly.”
Explain the most likely diagnosis based on history:
- “Your symptoms are concerning for possible angina, given that they occur with exertion and improve with rest.”
Reassure while emphasising need for further testing:
- “We need to do some tests to rule out serious causes, but at this stage, it is not an emergency.”
Discuss need for further investigations:
- “An ECG, blood tests, and possibly a stress test will help determine if your heart is involved.”
Ensure patient understanding using teach-back techniques.

Task 4: Develop a management plan, including immediate actions, investigations, and follow-up.

The competent candidate should:

Immediate management:
- If symptoms persist or worsen, refer to hospital for urgent evaluation.
- If stable, perform ECG in-clinic and arrange blood tests (troponin, lipids, HbA1c, renal function).
Further investigations:
- Exercise stress test or CT coronary angiogram, depending on pre-test probability.
- Echocardiogram if concerns about structural heart disease.
Cardiovascular risk factor management:
- Optimise hypertension, hyperlipidaemia, and lifestyle factors.
- Encourage smoking cessation and regular exercise.
Discuss medications if angina suspected:
- Consider aspirin, statin, beta-blocker, and GTN spray pending cardiology review.
Safety-netting and follow-up:
- “If you develop chest pain at rest, severe discomfort, or breathlessness, call 000 immediately.”
- “We will follow up in one week to discuss test results and next steps.”

SUMMARY OF A COMPETENT ANSWER

Takes a structured chest pain history, assessing urgency and red flags.
Considers a broad differential diagnosis, distinguishing cardiac from non-cardiac causes.
Explains findings clearly and empathetically, addressing patient anxiety.
Develops an appropriate management plan, including ECG, blood tests, and risk factor control.
Provides clear safety-netting and follow-up instructions.

PITFALLS

Failing to consider cardiac causes, misdiagnosing as anxiety or musculoskeletal pain.
Overlooking risk factors, missing an opportunity for prevention.
Not arranging appropriate investigations, delaying diagnosis.
Providing vague reassurance without safety-netting, risking misdiagnosis of serious conditions.
Failing to explore patient concerns, leading to dissatisfaction or non-compliance.

REFERENCES

MARKING

Each competency area is assessed on the following scale from 0 to 3:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency Areas Assessed

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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history of chest pain and associated symptoms.
2.2 Assesses cardiovascular risk factors and need for further investigation.
2.3 Identifies indications for referral or emergency management.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between cardiac, musculoskeletal, gastrointestinal, and other causes.
3.3 Determines when referral or urgent hospitalisation is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an acute and long-term management plan.
4.3 Provides patient-centred education on risk factor modification.
4.5 Recognises when urgent escalation is required.

5. Preventive and Population Health

5.2 Discusses cardiovascular risk reduction strategies.

7. General Practice Systems and Regulatory Requirements

7.2 Understands appropriate referral pathways for suspected ACS.

Competency at Fellowship Level

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