CCE-CE-188

CASE INFORMATION

Case ID: SOB-008
Case Name: Michael Thompson
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R02 (Shortness of Breath/Dyspnoea)​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient with empathy and active listening
1.2 Explains differential diagnoses and management clearly
1.5 Uses structured communication to address patient concerns
2. Clinical Information Gathering and Interpretation2.1 Takes a thorough history of shortness of breath, including onset, triggers, and associated symptoms
2.2 Identifies red flags requiring urgent escalation
3. Diagnosis, Decision-Making and Reasoning3.1 Forms an appropriate differential diagnosis
3.2 Differentiates between respiratory, cardiac, and systemic causes of dyspnoea
4. Clinical Management and Therapeutic Reasoning4.2 Develops an immediate and long-term management plan
4.3 Determines when investigations and hospital referral are required
5. Preventive and Population Health5.1 Identifies and addresses modifiable risk factors for dyspnoea (e.g., smoking, obesity, heart disease)
5.3 Provides education on lifestyle modifications to improve respiratory function
6. Professionalism6.2 Maintains patient confidentiality and ensures a patient-centred approach
7. General Practice Systems and Regulatory Requirements7.3 Ensures appropriate documentation and follow-up
9. Managing Uncertainty9.1 Recognises when urgent hospital referral or further investigations are required
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag features requiring immediate escalation of care

CASE FEATURES

  • 72-year-old male presenting with progressive shortness of breath over the past three months.
  • No acute distress but worsening exertional dyspnoea.
  • History of smoking, hypertension, and previous myocardial infarction.
  • Concerns about possible heart failure, COPD, or interstitial lung disease.
  • Needs assessment of red flags (e.g., orthopnoea, paroxysmal nocturnal dyspnoea, weight loss, haemoptysis).
  • Discussion around investigations (CXR, ECG, echocardiogram, spirometry) and referral if needed.

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 a physical examination.

A patient record summary is provided for your information.

Perform the following tasks:

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

SCENARIO

Michael Thompson, a 72-year-old retired teacher, presents with gradually worsening shortness of breath over the past three months. He first noticed it while walking uphill, but now feels breathless even with normal activities like dressing and showering.

He denies acute chest pain but sometimes feels a dull heaviness in his chest after exertion. He sleeps with two pillows and has woken up gasping for air a few times at night. He has occasional swelling in his ankles by the end of the day.

PATIENT RECORD SUMMARY

Patient Details

  • Name: Michael Thompson
  • Age: 72
  • Gender: Male
  • Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Amlodipine 5 mg daily (for hypertension)
  • Aspirin 100 mg daily (post-MI)
  • Atorvastatin 40 mg daily

Past History

  • Hypertension (diagnosed 10 years ago, well controlled)
  • Myocardial infarction 5 years ago
  • Ex-smoker (30 pack-years, quit 8 years ago)

Social History

  • Retired teacher, lives with wife
  • Minimal alcohol intake, non-smoker

Family History

  • Father had heart failure in his 70s
  • No known lung disease or malignancy in the family

Vaccination and Preventive 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 getting more breathless over the past few months. At first, it was just going uphill, but now even getting dressed makes me puffed out.”

General Information

(Freely Shared if Asked Open-Ended Questions)

  • The breathlessness started about three months ago.
  • Initially, it was only noticeable when walking uphill, but it has gradually worsened.
  • Now, I feel short of breath even doing simple things like getting dressed, showering, or walking to the letterbox.
  • I sometimes feel a heavy sensation in my chest after exertion, but it goes away with rest.

Specific Information

(Only If Asked Targeted Questions)

Background Information

  • No sharp chest pain, dizziness, or fainting.
  • I sleep with two pillows at night but have started waking up gasping for air occasionally.
  • My ankles swell up by the evening, but the swelling reduces overnight.
  • I feel more tired than usual, but I thought it was just ageing.
  • My wife pointed out that I seem to be breathing faster than before.

Cardiac Symptoms

  • No sudden or severe chest pain.
  • No palpitations, dizziness, or fainting.
  • I had a heart attack five years ago but haven’t had any chest pain like that since.
  • No history of atrial fibrillation or heart failure.

Respiratory Symptoms

  • No chronic cough or phlegm.
  • No recent respiratory infections.
  • No wheezing or asthma history.
  • No past diagnosis of COPD or lung disease.

Systemic Symptoms and Red Flags

  • Unintentional weight loss (about 4 kg in two months).
  • Appetite is normal, and I have no difficulty swallowing.
  • No fevers, night sweats, or recent infections.
  • No coughing up blood (haemoptysis).

Lifestyle and Medication History

  • I take amlodipine for blood pressure, aspirin, and atorvastatin.
  • I quit smoking eight years ago but smoked a pack a day for 30 years.
  • No alcohol or recreational drug use.
  • Haven’t had a GP check-up in years.

Emotional Cues & Reactions

  • Concerned about what’s causing this—not sure if it’s my heart or lungs.
  • Frustrated that it’s limiting my daily activities—I used to enjoy walking but now avoid it.
  • Slightly worried about my weight loss but thought it might be due to less appetite or old age.
  • Wife is more concerned than me, she keeps telling me to get checked out.
  • Relieved if the doctor explains the possible causes and next steps clearly.

Questions the Patient Might Ask

  1. “Do you think this is my heart or my lungs?”
  2. “Do I need tests, like a scan or a stress test?”
  3. “Is this just part of getting older?”
  4. “Could this be serious, like cancer?”
  5. “What can I do to get my breath back?”
  6. “Will I have to be on oxygen or take puffers?”

How to Play the Role

Opening Scene (First Few Minutes)

  • Appear slightly concerned but not in distress.
  • Speak calmly but take occasional deep breaths, as if slightly winded.
  • Look slightly uncomfortable when describing breathlessness on exertion.

If the Doctor Asks About Symptoms Thoroughly:

  • Provide clear answers, emphasising that the breathlessness has worsened gradually.
  • Acknowledge the weight loss but don’t seem overly worried about it.

If the Doctor Dismisses the Concerns Too Quickly:

  • Look unconvinced and press for more details.
  • Say, “But it’s getting worse, and I don’t want to ignore something serious.”

If the Doctor Discusses Investigations (e.g., ECG, CXR, Spirometry, Echocardiogram):

  • Ask if these tests are really necessary.
  • Show relief if the tests help clarify the cause.

If the Doctor Mentions Heart Failure or COPD:

  • Look slightly worried, ask, “Is that serious? Can it be treated?”
  • Open to making lifestyle changes if explained well.

Ending the Consultation (Final Reaction Depending on the Doctor’s Approach)

If the Doctor Provides a Clear Plan and Reassurance:

  • Look relieved and say, “That makes sense. I’ll get the tests done.”
  • Agree to follow up and make lifestyle changes if needed.

If the Doctor Is Unclear or Dismissive:

  • Look hesitant and unconvinced.
  • Say, “I guess I’ll wait and see if it gets worse.”
  • Less likely to follow up.

Key Features for the Examiner to Observe

  • Comprehensive history-taking, covering cardiac, respiratory, and systemic causes of dyspnoea.
  • Recognition of red flags, including orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling, and weight loss.
  • Consideration of key differentials, including heart failure, COPD, anaemia, interstitial lung disease, and malignancy.
  • Clear communication, explaining the need for investigations (e.g., CXR, ECG, BNP, echocardiogram, spirometry).
  • Addressing patient concerns, particularly fear of cancer or heart failure.

Summary

This role-player script presents a realistic and clinically relevant case where the candidate must:

  1. Take a structured history, assessing breathlessness progression, associated symptoms, and red flags.
  2. Consider key differential diagnoses, including cardiac failure, respiratory disease, and systemic illness.
  3. Develop an appropriate management plan, including investigations, treatment, and follow-up.
  4. Address patient concerns effectively, ensuring clear explanations and reassurance.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a detailed history of the patient’s shortness of breath, including onset, progression, and associated symptoms.

The competent candidate should:

  • Elicit key details of the dyspnoea:
    • Onset: Acute vs. chronic (progression over three months).
    • Triggers: Exertion, lying flat, environmental factors.
    • Associated symptoms: Chest pain, ankle swelling, cough, wheeze, weight loss, night sweats.
  • Assess red flag symptoms:
    • Orthopnoea and paroxysmal nocturnal dyspnoea (PND) → Suggests heart failure.
    • Haemoptysis or significant weight loss → Concern for malignancy or interstitial lung disease.
  • Review past medical history and risk factors:
    • Hypertension, past myocardial infarction (risk of heart failure).
    • Smoking history (risk of COPD, lung malignancy).
    • Medications: Assess adherence and side effects.

Task 2: Formulate an appropriate differential diagnosis, considering cardiac, respiratory, and systemic causes.

The competent candidate should:

  • Cardiac causes:
    • Heart failure (progressive dyspnoea, orthopnoea, ankle swelling).
    • Ischaemic heart disease (exertional dyspnoea, mild chest heaviness).
  • Respiratory causes:
    • Chronic obstructive pulmonary disease (COPD) (smoking history, exertional dyspnoea).
    • Pulmonary fibrosis (progressive dyspnoea, weight loss).
    • Pulmonary embolism (if acute worsening or pleuritic pain).
  • Systemic causes:
    • Anaemia (fatigue, pallor, possible GI malignancy).
    • Malignancy (weight loss, persistent symptoms).

Task 3: Explain the likely cause of the dyspnoea, including the need for further investigations.

The competent candidate should:

  • Explain that heart failure is a likely cause, given:
    • Progressive breathlessness with exertion and at rest.
    • PND and orthopnoea.
    • Ankle swelling and weight loss.
  • Discuss why further investigations are required, including:
    • Echocardiogram to assess left ventricular function.
    • Chest X-ray to check for pulmonary congestion, effusion, or lung pathology.
    • Spirometry if COPD is suspected.
    • ECG and BNP to assess cardiac strain.
  • Reassure the patient that identifying the cause will help guide treatment and improve symptoms.

Task 4: Develop a management plan, including appropriate tests, lifestyle modifications, and follow-up.

The competent candidate should:

  • Arrange investigations:
    • Urgent echocardiogram, chest X-ray, ECG, and BNP.
    • Blood tests (FBC, UEC, LFTs, iron studies for anaemia, TFTs).
  • Initiate appropriate treatment:
    • If heart failure is suspected → Consider diuretics, ACE inhibitors, beta-blockers.
    • If COPD is suspected → Consider inhalers, smoking cessation, pulmonary rehab.
  • Provide lifestyle advice:
    • Sodium and fluid restriction for heart failure.
    • Smoking cessation and weight management.
  • Ensure follow-up:
    • Review results and adjust treatment accordingly.
    • Consider specialist referral (cardiology or respiratory) if needed.
    • Safety-net for worsening symptoms, especially new chest pain or severe breathlessness.

SUMMARY OF A COMPETENT ANSWER

  • Thorough history-taking, covering onset, triggers, and red flag symptoms.
  • Consideration of key differentials, including cardiac, respiratory, and systemic causes.
  • Clear explanation of likely diagnosis, with a structured approach to investigations.
  • Comprehensive management plan, including medications, lifestyle modifications, and follow-up.
  • Empathetic communication, addressing patient concerns about worsening symptoms and weight loss.

PITFALLS

  • Failing to recognise red flag symptoms, such as orthopnoea, PND, or weight loss.
  • Overlooking cardiac causes, particularly heart failure in an elderly patient with a past MI.
  • Not considering COPD, despite a significant smoking history.
  • Relying on medications alone, without addressing lifestyle factors and risk modification.
  • Not explaining the need for follow-up, leading to delayed diagnosis and worsening symptoms.

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.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history of shortness of breath, including onset, triggers, and associated symptoms.
2.2 Identifies red flags requiring urgent escalation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.2 Differentiates between respiratory, cardiac, and systemic causes of dyspnoea.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an immediate and long-term management plan.
4.3 Determines when investigations and hospital referral are required.

5. Preventive and Population Health

5.1 Identifies and addresses modifiable risk factors for dyspnoea.
5.3 Provides education on lifestyle modifications to improve respiratory function.

9. Managing Uncertainty

9.1 Recognises when urgent hospital referral or further investigations are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag features requiring immediate escalation of care.

Competency at Fellowship Level

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