CCE-CE-149 - GP Exams

CASE INFORMATION

Case ID: CCE-CHS-004
Case Name: Michael Turner
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A04 – Chest symptom/complaint

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear explanations about the condition and management options
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history of the chest symptom (onset, nature, associated symptoms) 2.2 Identifies risk factors for cardiac, respiratory, or musculoskeletal causes
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between life-threatening and non-life-threatening causes 3.2 Identifies red flags requiring urgent escalation
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe, evidence-based management plan 4.2 Initiates appropriate investigations and referrals if required
5. Preventive and Population Health	5.1 Discusses modifiable cardiovascular risk factors (e.g., smoking, diet, physical activity)
6. Professionalism	6.1 Provides patient-centred, non-judgmental care
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and safety netting
9. Managing Uncertainty	9.1 Balances risk vs reassurance in a patient with an undifferentiated chest complaint
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and escalates care for a potentially serious condition

CASE FEATURES

Wants to know if he needs urgent tests or if it’s something minor.
58-year-old male presents with chest discomfort for the past few weeks.
Describes pressure-like sensation in the centre of his chest, worse with exertion.
Has risk factors for cardiovascular disease (hypertension, overweight, family history).
Unsure if it is heart-related, musculoskeletal, or reflux.

INSTRUCTIONS

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

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

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

Michael Turner, a 58-year-old accountant, presents with chest discomfort that started 3 weeks ago. He describes it as a pressure-like sensation in the middle of his chest, particularly when walking uphill or after heavy meals. It eases with rest and hasn’t been sudden or severe, but it is happening more often now.

His medical history includes:

Hypertension (diagnosed 5 years ago, on perindopril 5 mg daily).
Overweight (BMI 29).
Occasional episodes of reflux, but not on regular medication.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Turner
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies.

Medications

Perindopril 5 mg daily

Past History

Hypertension (5 years, managed with medication).
Mild reflux symptoms, not on medication.

Social History

Sedentary job, overweight (BMI 29).
Occasional alcohol, no smoking.

Preventive Activities

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’ve been having this pressure-like feeling in my chest for the last few weeks. It’s not always there, but it seems to happen when I walk fast or after eating. Do you think it’s my heart?”

General Information

You are Michael Turner, a 58-year-old accountant. You’ve come to see your GP because of a chest discomfort that has been bothering you for the past three weeks. You’re worried it might be heart-related, especially since your father had a heart attack at 60.

Specific Information

(To be revealed only when asked)

Background Information

You first noticed the discomfort about three weeks ago when you were walking uphill to the shops. It felt like a pressure in the middle of your chest, but it eased when you stopped to rest. Since then, it’s happened multiple times, usually when walking quickly or after eating a big meal. The discomfort is not sudden or sharp, and you haven’t had any major attacks, but it seems to be getting worse.

You’re worried and not sure if this is serious or something minor like reflux or muscle strain.

Symptoms – Chest Pain Characteristics

Dull, pressure-like discomfort in the centre of the chest.
Not sharp or stabbing.
Worse with exertion (walking uphill, brisk walking).
Also happens after eating large meals.
Eases after a few minutes of rest.
Does not radiate to the arm, jaw, or back.
No palpitations, dizziness, or fainting.
Occasionally short of breath with the pain, but not severely.

Past Medical History

Hypertension (diagnosed 5 years ago, on perindopril 5 mg daily).
Occasional reflux symptoms, not on regular medication.
Overweight (BMI 29).
No history of previous heart issues or hospitalisations.

Family History

Father had a heart attack at 60.

Lifestyle and Social History

Works as an accountant, mostly sedentary.
Occasionally drinks alcohol.
Never smoked.
No regular exercise, but wants to start improving health.

Emotional Cues and Responses

If the doctor is reassuring and explains things well, you feel relieved but still cautious.
If the doctor dismisses your concerns, you feel frustrated and anxious.
If the doctor suggests tests but doesn’t explain why, you feel nervous.
If the doctor strongly recommends lifestyle changes, you feel slightly guilty but motivated.
If the doctor mentions hospital, you start to panic a little.

Possible Emotional Reactions Based on Doctor’s Approach

Doctor’s Approach	Your Likely Reaction
Explains things clearly and calmly	You feel reassured and are more open to lifestyle changes.
Dismisses your concerns as minor without proper explanation	You feel frustrated and may consider seeking a second opinion.
Pushes for multiple tests without explaining why	You feel anxious and uncertain about your health.
Recommends hospitalisation immediately without clear reasoning	You panic and feel overwhelmed.

Questions for the Candidate

You are likely to ask some or all of the following:

“Do I need an ECG or blood tests?”
“Could this be angina or a sign of a heart attack?”
“What happens if I ignore this?”
“Could this just be stress or heartburn?”
“Should I be going to the hospital instead of seeing you?”
“What can I do to stop this from getting worse?”
“If I start exercising, will it help or make it worse?”

Patient Behaviours and Reactions

If the doctor explains things well and gives a clear plan:

You feel reassured and willing to follow recommendations.
You ask about next steps, such as lifestyle changes, medications, or tests.

If the doctor is vague or dismisses your concerns:

You become frustrated and anxious.
You doubt the diagnosis and may insist on more tests or a referral.

If the doctor strongly recommends immediate lifestyle changes:

You acknowledge that you need to make changes but may feel overwhelmed.
You express willingness to try but need guidance on where to start.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, character, and associated symptoms of the chest complaint, as well as relevant cardiovascular risk factors.

The competent candidate should:

Use open-ended questions to allow the patient to describe symptoms.
Identify key features of chest discomfort:
- Onset: When did the symptoms begin?
- Character: Pressure-like, sharp, or burning?
- Location and radiation: Does the pain spread to the arms, jaw, or back?
- Exacerbating/relieving factors: Worse with exertion? Better with rest?
- Associated symptoms: Breathlessness, nausea, dizziness, palpitations?
Assess cardiovascular risk factors, including:
- History of hypertension, diabetes, dyslipidaemia, smoking, family history of heart disease.
Evaluate for alternative causes, such as reflux, musculoskeletal pain, or anxiety.

Task 2: Assess and explain the likely differential diagnoses, including cardiac vs non-cardiac causes of chest pain.

The competent candidate should:

Explain that chest pain can have multiple causes, including:
- Cardiac (must rule out first): Angina, acute coronary syndrome.
- Gastro-oesophageal: Reflux disease, oesophageal spasm.
- Musculoskeletal: Costochondritis, muscle strain.
- Pulmonary: Pulmonary embolism, pneumonia.
- Psychological: Anxiety, panic attack.
Reassure the patient that a structured approach will help determine the cause.

Task 3: Provide a structured management plan, including investigations, immediate safety netting, and follow-up plan.

The competent candidate should:

Order appropriate investigations, including:
- ECG to assess for ischaemic changes.
- Troponin (if concerned about acute coronary syndrome).
- Lipid profile, fasting glucose, HbA1c (if cardiovascular risk assessment needed).
- Echocardiogram or stress test if angina is suspected.
Safety-net the patient, explaining when to seek emergency care (e.g., worsening pain, sudden severe symptoms).
Offer lifestyle advice:
- Smoking cessation (if applicable), weight loss, dietary changes.
- Exercise guidance based on the final diagnosis.
Arrange follow-up to review test results and adjust management accordingly.

Task 4: Address the patient’s concerns regarding serious illness, need for tests, and possible treatment options.

The competent candidate should:

Reassure the patient that their symptoms are being taken seriously.
Explain the need for investigations to rule out heart disease.
Provide a clear action plan: If urgent hospitalisation is required, explain why. If outpatient follow-up is appropriate, discuss next steps.
Encourage the patient to ask questions and express any remaining concerns.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history of the chest pain, focusing on red flags.
Explains differential diagnoses, prioritising cardiac causes first.
Orders appropriate investigations, including ECG, blood tests, and possible referral for further testing.
Provides clear safety-netting, instructing the patient when to seek urgent care.
Addresses concerns empathetically, ensuring the patient understands their condition and next steps.

PITFALLS

Failing to consider a cardiac cause first, especially in a patient with risk factors.
Reassuring the patient prematurely without appropriate investigations.
Over-ordering tests without clinical justification (e.g., ordering a stress test when simple musculoskeletal pain is likely).
Not providing clear safety-netting (e.g., failing to advise when to call an ambulance).
Dismissing the patient’s concerns without a structured explanation.

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.
☑ 1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

☑ 2.1 Takes a thorough history of the chest symptom.
☑ 2.2 Identifies risk factors for cardiovascular disease.

3. Diagnosis, Decision-Making and Reasoning

☑ 3.1 Differentiates between life-threatening and non-life-threatening causes.
☑ 3.2 Identifies red flags requiring urgent escalation.

4. Clinical Management and Therapeutic Reasoning

☑ 4.1 Develops a safe, evidence-based management plan.
☑ 4.2 Initiates appropriate investigations and referrals if required.

5. Preventive and Population Health

☑ 5.1 Discusses modifiable cardiovascular risk factors (e.g., smoking, diet, physical activity).

6. Professionalism

☑ 6.1 Provides patient-centred, non-judgmental care.

7. General Practice Systems and Regulatory Requirements

☑ 7.1 Ensures appropriate documentation and safety netting.

9. Managing Uncertainty

☑ 9.1 Balances risk vs reassurance in a patient with an undifferentiated chest complaint.

10. Identifying and Managing the Patient with Significant Illness

☑ 10.1 Recognises and escalates care for a potentially serious condition.

Competency at Fellowship Level

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