CASE INFORMATION

Case ID: PVD-019
Case Name: David Reynolds
Age: 68 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K92 – Atherosclerosis/Peripheral Vascular Disease

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand concerns, ideas, and expectations 1.2 Provides clear explanations tailored to the patient’s level of health literacy 1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to assess symptoms, risk factors, and red flags 2.2 Identifies when further investigations are warranted
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for lower limb pain and walking limitations 3.2 Recognises red flags requiring urgent referral
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Provides appropriate treatment options and patient education
5. Preventive and Population Health	5.1 Discusses cardiovascular risk reduction strategies
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation, follow-up, and specialist referrals
9. Managing Uncertainty	9.1 Provides reassurance and safety-netting when the diagnosis is unclear
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when peripheral arterial disease is severe and requires urgent intervention

CASE FEATURES

Elderly male presenting with exertional leg pain, suggestive of peripheral vascular disease (PVD).
Exploring differential diagnoses, including neurogenic claudication, chronic venous insufficiency, and musculoskeletal pain.
Addressing patient concerns, including mobility issues, cardiovascular risks, and risk of amputation.
Balancing reassurance with appropriate investigation and timely 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:

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 Reynolds, a 68-year-old retired construction worker, presents with pain in his lower legs when walking that improves with rest. He describes the pain as aching and cramping, occurring after walking about 100 metres, and resolving within a few minutes of stopping.

He is worried about poor circulation and whether he might lose his leg.

PATIENT RECORD SUMMARY

Patient Details

Name: David Reynolds
Age: 68
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Aspirin 100mg daily
Atorvastatin 40mg daily
Perindopril 5mg daily (for hypertension)
Metformin 500mg BD (for type 2 diabetes)

Past History

Hypertension (diagnosed 15 years ago)
Type 2 diabetes (diagnosed 10 years ago, HbA1c 7.5%)
Hypercholesterolaemia
History of smoking (quit 5 years ago, 40 pack-years total)

Social History

Retired, previously worked in construction.
Drinks 2-3 glasses of wine per week.

Family History

Father had a stroke at age 72.
Brother had a heart attack at 65.

Smoking

Smoked 40 pack-years, quit 5 years ago.

Alcohol

Drinks socially, 2-3 times per week.

Vaccination and Preventative Activities

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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I keep getting cramps in my legs when I walk, and I have to stop to let them ease. I’m worried about my circulation—could I lose my leg?”

General Information

Your name is David Reynolds, and you are 68 years old.
You are a retired construction worker, living with your wife.
You are generally independent but have reduced your physical activity due to leg pain.
You were diagnosed with type 2 diabetes 10 years ago, and it has been managed with metformin.

Specific Information

(Reveal only when asked directly)

You have a long history of high blood pressure and high cholesterol, for which you take perindopril, atorvastatin, and aspirin.
You smoked for 40 years but quit 5 years ago.
Over the past year, you have developed aching and cramping pain in both calves when walking.
The pain occurs after about 100 metres and goes away when you rest.
Recently, it seems to be getting worse, and you have to stop more often.
You have not noticed any swelling or redness in your legs.
You are worried about poor circulation and whether you might lose your leg.

Pain Characteristics

The pain is cramping and aching, not sharp or burning.
It happens in both legs, mainly the calves, but sometimes extends to the thighs.
It occurs only during walking, never when sitting or lying down.
It is relieved within 2-3 minutes of stopping.
You have no pain at rest, at night, or when elevating your legs.

Other Symptoms

No numbness, tingling, or weakness in the legs.
No pain in the back or shooting pain down the legs (ruling out sciatica).
No foot ulcers, open wounds, or darkened skin.
No signs of infection—no fever, redness, or swelling.

Lifestyle Factors

You quit smoking 5 years ago but had a 40-pack-year smoking history.
You drink 2-3 glasses of wine per week.
You don’t exercise regularly anymore because of the leg pain.
You eat a fairly high-salt diet, often including processed foods and takeaways.

Medications and Past Medical History

Aspirin 100mg daily (for cardiovascular prevention).
Atorvastatin 40mg daily (for high cholesterol).
Perindopril 5mg daily (for hypertension).
Metformin 500mg BD (for type 2 diabetes).
No history of heart attacks, strokes, or previous vascular surgery.
No history of deep vein thrombosis (DVT).

Family History

Father had a stroke at age 72.
Brother had a heart attack at 65.
No known family history of amputations.

Concerns and Expectations

You are worried this is serious and could lead to amputation.
You want to know if surgery is needed.
You are wondering if medication can improve circulation.
You want to remain independent and avoid disability.
You are also worried about your risk of heart attack or stroke.

Red Flag Symptoms (Reveal only when asked directly)

No foot ulcers or non-healing wounds.
No rest pain or pain at night.
No significant coldness or numbness in the feet.
No recent weight loss, fever, or generalised weakness.

Emotional Cues & Body Language

You appear worried and slightly tense.
If the doctor hesitates or seems unsure, you will ask:
- “But how do we know for sure? Should I have a heart scan?”
If the doctor only mentions lifestyle changes without discussing tests, you may ask:
- “But what if this is something serious? Shouldn’t we check first?”
If the doctor mentions stopping or changing medications, you will say:
- “I’ve been on these medications for years. Could they really be causing this now?”
If the doctor explains things clearly and provides a structured plan, you will feel reassured and ready to follow their advice.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Do I need surgery for this?”
“Can I do anything to stop it from getting worse?”
“Is there medication that can help?”
“What are the chances I could lose my leg?”
“Should I be worried about a stroke or heart attack?”
“Is this related to my diabetes?”
“Should I wear compression stockings?”
“Will exercise make this worse or better?”

Key Behaviours & Approach

You are worried but open to explanations and tests.
If the doctor only reassures you without suggesting investigations, you will say:
- “But how do we rule out something serious?”
If the doctor suggests a referral to a specialist, you will ask:
- “How long will that take? Do I need to do anything in the meantime?”
If the doctor explains things well and provides a clear plan, you will feel reassured and ready to proceed with the recommended investigations.

Additional Context for the Role-Player

You trust medical advice but want a logical explanation of what is happening.
You are not opposed to tests or referrals, but you want to understand why they are necessary.
You do not want to be dismissed or told it’s “just ageing” without a thorough assessment.
You want to be proactive about your health and understand how to manage or prevent worsening symptoms.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying features of claudication and cardiovascular risk factors.
Provide a differential diagnosis, considering PVD, neurogenic claudication, and venous disease.
Explain the need for investigations, including ABPI, Doppler ultrasound, and cardiovascular risk assessment.
Offer initial management strategies, including smoking cessation, structured walking programs, and medication review.
Address patient concerns empathetically, particularly regarding surgical options, long-term prognosis, and risk modification.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering potential causes of leg pain and vascular compromise.

The competent candidate should:

Clarify symptom onset, duration, and progression, noting walking distance before pain occurs and relief with rest.
Differentiate vascular from neurogenic or musculoskeletal causes, asking about back pain, neurological symptoms, or joint issues.
Assess for red flag symptoms, including rest pain, foot ulcers, skin colour changes, and gangrene.
Review risk factors for atherosclerosis, such as hypertension, diabetes, hyperlipidaemia, smoking history, and family history of cardiovascular disease.
Explore functional impact, assessing how symptoms affect daily activities and exercise tolerance.
Address the patient’s concerns, particularly fear of amputation and cardiovascular events.

Task 2: Formulate a differential diagnosis and explain it to the patient.

The competent candidate should:

Explain that peripheral vascular disease (PVD) is the most likely cause, given the intermittent claudication and risk factors.
Discuss other possible conditions, including:
- Neurogenic claudication (lumbar spinal stenosis) – if pain worsens with standing and improves with sitting.
- Chronic venous insufficiency – if associated with swelling, varicose veins, or skin changes.
- Diabetic neuropathy – if burning pain or numbness in a stocking distribution.
- Musculoskeletal pain (e.g., osteoarthritis, sciatica) – if linked to joint stiffness or specific movements.
Reassure the patient that many cases of PVD can be managed without surgery, but further testing is necessary to confirm severity.

Task 3: Address the patient’s concerns, including the need for investigations, potential outcomes, and lifestyle modifications.

The competent candidate should:

Acknowledge the patient’s anxiety about amputation, explaining that early intervention reduces this risk.
Explain the need for investigations, including:
- Ankle-Brachial Pressure Index (ABPI) – first-line test to assess arterial supply.
- Doppler ultrasound – to identify arterial narrowing.
- Blood tests – including fasting lipids, HbA1c, renal function, and inflammatory markers.
- ECG – to assess underlying cardiovascular risk.
Discuss lifestyle modifications, including:
- Supervised exercise therapy, which can improve walking distance.
- Smoking cessation, a key factor in slowing disease progression.
- Dietary changes to reduce cholesterol and manage diabetes.
Reassure the patient that medical therapy is available, including statins, antihypertensives, and antiplatelet agents.

Task 4: Develop an initial management plan, including further investigations, risk factor modification, and follow-up.

The competent candidate should:

Order appropriate investigations, such as:
- ABPI and Doppler ultrasound for vascular assessment.
- Blood tests (lipids, HbA1c, renal function, FBC) to assess modifiable risk factors.
- ECG if cardiovascular risk is high.
Prescribe and optimise medical therapy, including:
- Aspirin or clopidogrel (antiplatelet therapy) to prevent progression.
- Statins to manage hyperlipidaemia.
- Optimisation of blood pressure and diabetes control.
Recommend lifestyle interventions, such as:
- Supervised walking programs, increasing distance gradually.
- Smoking cessation strategies, including nicotine replacement therapy.
- Dietary changes, weight loss, and glycaemic control.
Consider referral to a vascular specialist if:
- Severe symptoms (pain at rest or tissue loss) are present.
- ABPI results suggest significant arterial insufficiency.
Arrange follow-up in 4-6 weeks to reassess symptoms and test results.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history, covering claudication symptoms, risk factors, and red flags.
Provides a structured differential diagnosis, considering vascular, neurological, and musculoskeletal causes.
Explains the need for investigations, including ABPI, Doppler ultrasound, and cardiovascular risk assessment.
Develops an evidence-based management plan, incorporating medications, lifestyle modifications, and possible referral.
Ensures appropriate follow-up, monitoring for progression or complications.

PITFALLS

Failing to assess for critical limb ischaemia, missing red flags like rest pain, ulcers, or gangrene.
Overlooking risk factor management, such as optimising diabetes control or lipid-lowering therapy.
Not considering alternative diagnoses, such as lumbar spinal stenosis or venous insufficiency.
Providing inadequate lifestyle advice, missing the opportunity to slow disease progression through exercise and smoking cessation.
Not scheduling follow-up, leading to disease progression without reassessment.

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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the patient’s concerns and sociocultural context.
1.2 Engages the patient to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history, including claudication symptoms, risk factors, and red flags.
2.2 Orders appropriate investigations, balancing clinical suspicion and patient safety.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis, prioritising vascular, neurological, and musculoskeletal causes.
3.2 Identifies indications for further assessment or referral, ensuring red flags are addressed.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a structured, evidence-based treatment plan, incorporating risk factor modification and potential specialist referral.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses lifestyle modifications, including smoking cessation, exercise therapy, and dietary changes.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety-netting, ensuring the patient understands when to seek further medical care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of critical limb ischaemia requiring urgent escalation.

Competency at Fellowship Level

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