CASE INFORMATION

Case ID: CCE-2024-001
Case Name: John Dawson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: K77 (Other Heart Disease)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
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, and the full impact of their illness experience. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant clinical history. 2.2 Interprets clinical findings and investigations appropriately.
3. Diagnosis, Decision-Making and Reasoning	3.1 Generates a safe and evidence-based differential diagnosis. 3.2 Identifies red flags requiring urgent intervention.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe, patient-centred management plan. 4.2 Considers pharmacological and non-pharmacological management.
5. Preventive and Population Health	5.1 Discusses cardiovascular risk factor modification.
6. Professionalism	6.1 Maintains professional standards of care and patient advocacy.
7. General Practice Systems and Regulatory Requirements	7.1 Uses appropriate referral pathways (e.g. cardiology).
8. Procedural Skills	8.1 Demonstrates understanding of ECG interpretation and point-of-care testing.
9. Managing Uncertainty	9.1 Recognises when a patient requires further investigation or specialist input.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and safely manages a patient at risk of deterioration.

CASE FEATURES

Wants to know the next steps and treatment options.
67-year-old male presenting with shortness of breath and fatigue.
History of ischaemic heart disease and hypertension.
New bilateral lower limb oedema over 4 weeks.
Recent weight gain and difficulty sleeping flat.
Concerned about heart failure or worsening heart condition.
Has not seen a cardiologist for 2 years.

INSTRUCTIONS

You have 15 minutes to complete 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

John Dawson, a 67-year-old retired accountant, presents to your general practice clinic with worsening shortness of breath and fatigue over the past month. He reports swollen ankles and has gained 3 kg in the past month.

John is concerned this could be heart failure and wants to know if he needs to go to hospital or change his medications. He lives alone but has good family support nearby.

PATIENT RECORD SUMMARY

Patient Details

Name: John Dawson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 5mg daily
Atorvastatin 40mg daily
Aspirin 100mg daily

Past History

Ischaemic heart disease (PCI 5 years ago)
Hypertension
Hypercholesterolaemia

Social History

Lives alone, but family nearby

Family History

Father had an MI at age 55
Mother had type 2 diabetes

Smoking & Alcohol

Non-smoker
Alcohol: 3-4 standard drinks 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’ve been feeling really short of breath lately, and my ankles are swelling. Could this be my heart getting worse?”

General Information

John Dawson is a 67-year-old retired accountant who has been experiencing worsening shortness of breath and ankle swelling over the past four weeks. He first noticed his legs getting puffy but didn’t think much of it. However, his symptoms have progressed to the point where he now struggles with breathlessness on exertion and difficulty sleeping flat at night.

Specific Information

(Only if asked directly by the candidate)

Background Information

He has a history of ischaemic heart disease, hypertension, and high cholesterol. He had a stent placed five years ago after a mild heart attack but has been stable since then. He takes amlodipine, atorvastatin, and aspirin, but he has not seen his cardiologist for two years.

John lives alone, though his daughter and son live nearby and check in on him. He is independent in daily activities, but his recent symptoms have made walking and going up stairs more difficult.

Symptoms and Progression

Swelling started a month ago – at first mild but now noticeable in both ankles.
Gained about 3 kg in a month without any change in diet.
Breathlessness started 3 weeks ago – worse on exertion and at night.
Now struggles with stairs and brisk walking – gets breathless after a few minutes.
Feels worse when lying flat – sleeps with two pillows.

Associated Symptoms

No chest pain but sometimes mild tightness in the chest.
No dizziness or fainting.
No palpitations or skipped heartbeats.
No recent infections, fevers, or cough.

Medication and Compliance

Takes his medications regularly.
Has not changed his diet significantly – eats a low-salt diet.
No new medications or supplements.
Has not missed any doses.

Medical History & Follow-up

Hypertension and high cholesterol – well-controlled.
Had a stent placed five years ago – stable since.
Last saw his cardiologist two years ago.
No history of diabetes.
No previous heart failure diagnosis.

Social History & Functioning

Lives alone, but son and daughter visit often.
Still drives, but is unsure if that’s safe.
Ex-smoker (quit 10 years ago).
Drinks 3-4 standard drinks per week.
Retired accountant – stays active with gardening and occasional walks.

Patient Concerns and Expectations

“Doctor, do you think this could be heart failure?”
“Will I need more heart tests or go to hospital?”
“Could my stent be blocked again?”
“Do I need to change my medications?”
“Is it still safe for me to drive?”

If the doctor seems unsure or does not address his concerns clearly, he might say:

“Doctor, this is really worrying me. Should I go to the hospital?”
“I feel like I’m getting worse. Is there anything serious happening?”

If the doctor mentions heart failure, John reacts with some anxiety and concern, saying:

“Oh no, does that mean my heart is failing completely?”
“Is this going to get worse over time?”
“What can I do to fix it or slow it down?”

If the candidate discusses lifestyle changes, John is receptive but unsure:

“I already watch my salt intake – do I need to do even more?”
“I try to stay active, but lately, I feel too tired to do much.”

If the candidate doesn’t mention referral to a cardiologist, John asks:

“Should I see a heart specialist again?”

If the doctor recommends urgent referral, John hesitates:

“I don’t really want to go to the hospital unless I have to.”
“Can’t we just adjust my medications and see if I feel better?”

Emotional Cues and Behaviour

Mildly anxious about his symptoms but not panicked.
Leans forward slightly while talking – appears a bit breathless.
Becomes more concerned when heart failure is mentioned.
Looks relieved if the doctor explains the condition clearly.

Escalation Cues (For an Excellent Candidate)

If the doctor fails to explore his driving concerns, John asks:

“Doctor, if my heart’s not working well, can I still drive safely?”

If the candidate does not discuss long-term management, John asks:

“If this is heart failure, does that mean I’ll need stronger medications forever?”

If the candidate does not discuss tests, John prompts:

“Will I need another heart scan or ECG to check things out?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a structured history from John Dawson regarding his symptoms

The competent candidate should:

Establish the onset, duration, and progression of shortness of breath and ankle swelling.
Inquire about orthopnoea (difficulty lying flat), paroxysmal nocturnal dyspnoea, and exercise tolerance.
Assess weight changes, fatigue, and fluid retention.
Ask about associated symptoms such as chest pain, palpitations, dizziness, syncope, or cough.
Review medication adherence and any recent changes.
Explore risk factors such as previous cardiac events, smoking, alcohol use, and family history of cardiovascular disease.

Task 2: Explain the likely diagnosis and differential diagnoses to the patient

The competent candidate should:

Explain that heart failure is the likely cause given his history of ischaemic heart disease, hypertension, and worsening symptoms.
Discuss other possible causes (e.g., fluid overload due to kidney disease, anaemia, or medication side effects).
Explain why his stent is unlikely to be the cause but should still be monitored.

Task 3: Outline the investigations required to confirm the diagnosis

The competent candidate should:

Order a chest X-ray to assess for pulmonary congestion or cardiomegaly.
Request blood tests including full blood count, renal function, liver function, electrolytes, NT-proBNP, and thyroid function.
Perform an ECG to check for arrhythmias or evidence of prior infarction.
Arrange an echocardiogram to assess ejection fraction and cardiac function.

Task 4: Develop a management plan for the patient

The competent candidate should:

Initiate diuretics (e.g., furosemide) for symptomatic relief.
Consider starting or optimising beta-blockers, ACE inhibitors, or aldosterone antagonists.
Provide lifestyle advice (e.g., low-salt diet, daily weight monitoring, fluid restriction if needed).
Refer to a cardiologist for ongoing management.
Discuss driving safety and advise the patient on when to avoid driving if symptoms worsen.
Schedule a review within a week to reassess symptoms and response to treatment.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, including symptom progression, impact, and risk factors.
Clear explanation of likely heart failure while addressing the patient’s concerns.
Ordering appropriate tests (CXR, ECG, echocardiogram, blood tests).
Initiating immediate management, including diuretics, medication optimisation, and lifestyle changes.
Providing a follow-up plan and discussing referral to a cardiologist.
Addressing the patient’s concerns about prognosis, driving, and daily activities.

PITFALLS

Failing to recognise worsening heart failure and delaying urgent management.
Not addressing orthopnoea or weight gain, missing key symptoms.
Neglecting to assess medication adherence and potential side effects.
Not ordering essential investigations, especially NT-proBNP and echocardiogram.
Failing to explain the need for medication changes and lifestyle modifications.
Not discussing driving safety in a patient with worsening cardiac symptoms.

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

2. Clinical Information Gathering and Interpretation

2.1 Uses an organised and logical approach to history-taking.
2.2 Identifies relevant symptoms and risk factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates an appropriate differential diagnosis.
3.2 Identifies red flags and the need for urgent intervention.

4. Clinical Management and Therapeutic Reasoning

4.1 Initiates an evidence-based treatment plan.
4.2 Provides rationale for medication choices.
4.3 Offers clear lifestyle and follow-up advice.

5. Preventive and Population Health

5.1 Discusses risk factor modification (e.g., salt intake, exercise, smoking cessation).

6. Professionalism

6.1 Demonstrates empathy and patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.1 Recognises the need for referral to a cardiologist.
7.2 Advises on fitness to drive per Australian guidelines.

9. Managing Uncertainty

9.1 Recognises the need for ongoing monitoring and reassessment.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies worsening heart failure and acts promptly.

Competency at Fellowship Level

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