CASE INFORMATION
Case ID: DMFU-2025-001
Case Name: George Stevens
Age: 68
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T90 Diabetes; non-insulin-dependent, S97 Chronic Ulcer
COMPETENCY OUTCOMES
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | 1.1 Communicate effectively and respectfully 1.2 Use effective health education strategies to promote health and wellbeing 1.3 Communicate in a culturally safe and respectful manner |
| 2. Clinical Information Gathering and Interpretation | 2.1 Gather relevant and sufficient clinical information |
| 3. Diagnosis, Decision-Making and Reasoning | 3.1 Make rational clinical decisions and diagnoses |
| 4. Clinical Management and Therapeutic Reasoning | 4.1 Develop effective and appropriate management plans 4.2 Implement safe and quality therapeutic strategies |
| 5. Preventive and Population Health | 5.1 Implement preventive health measures |
| 6. Professionalism | 6.1 Demonstrate respectful and ethical conduct |
| 7. General Practice Systems and Regulatory Requirements | 7.1 Work effectively within the general practice system |
| 8. Procedural Skills | 8.1 Provide basic wound care management |
| 9. Managing Uncertainty | 9.1 Manage clinical uncertainty effectively |
| 10. Identifying and Managing the Patient with Significant Illness | 10.1 Identify and manage patients with complex medical needs |
CASE FEATURES
- Preventive health approach, including risk factor modification and patient education
- Diabetes management complexity
- Chronic foot ulceration
- Concerns regarding wound healing and infection
- Assessment of patient knowledge and adherence to diabetes care
- Holistic and multidisciplinary management
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
George Stevens, aged 68, is a retired truck driver who presents to your general practice clinic with a chronic foot ulcer on his left foot. He has had Type 2 Diabetes for 15 years, which is currently managed with oral medications. George mentions that the ulcer has been present for six weeks and appears to be getting larger. He describes a dull ache and occasional discharge but denies significant pain.
PATIENT RECORD SUMMARY
Patient Details
Name: George Stevens
Age: 68
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Penicillin (rash)
Medications
- Metformin XR 1000mg daily
- Gliclazide MR 60mg daily
- Atorvastatin 40mg daily
- Perindopril 5mg daily
Past History
- Type 2 Diabetes Mellitus diagnosed 15 years ago
- Hypertension
- Hyperlipidaemia
- Previous smoker (ceased 10 years ago)
Social History
- Retired truck driver
Family History
- Father had diabetes and died from a myocardial infarction at 72
- Mother passed away from stroke at 80
Smoking
- Ex-smoker (ceased 10 years ago)
Alcohol
- Drinks 3-4 beers per week socially
Vaccination and Preventative Activities
- Pneumococcal vaccine received 3 years ago
- Influenza vaccine annually
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.
Opening Line
“Doctor, I’m really worried about this ulcer on my foot, it just won’t heal.”
General Information
(Provide freely if prompted with open-ended questions like “Tell me more about that.”)
- You first noticed the ulcer around six weeks ago. It happened after you accidentally scraped your left foot on a concrete step outside your house. At first, it seemed trivial—just a small sore. You didn’t think much of it, expecting it to heal on its own.
- Instead, the ulcer has been getting bigger and deeper slowly. Occasionally, you’ve noticed some clear-yellowish discharge. It’s not heavily discharging, but enough that you find it irritating and bothersome.
Specific Information
(Provide ONLY when asked specifically)
Background Information
- You don’t feel significant pain because you have less feeling in your feet, something your previous GP had mentioned as a complication of your diabetes.
- You’ve tried managing it yourself by using dressings you bought from the local pharmacy and antiseptic solutions, but it hasn’t helped much.
- You’re particularly worried because your neighbour recently experienced a similar ulcer that became severely infected, resulting in amputation of his leg below the knee. This has raised considerable fear and anxiety for you, prompting today’s visit.
About the Foot Ulcer
- It is on the sole of your left foot, just beneath your big toe.
- It began as a small scrape around 1 cm wide, but has gradually enlarged and is now around 4 cm wide.
- The wound looks raw and deep, and occasionally leaks clear-yellowish fluid.
- There is no bad smell from the ulcer at present.
- You don’t feel intense pain—more like a dull ache—because you know you have reduced sensation in your feet.
- You haven’t noticed any fever, chills or general unwell feelings.
- You have observed mild swelling around the area of the ulcer but no redness extending significantly beyond the edges of the wound.
Diabetes Management and Medical Background
- You have had Type 2 diabetes for about 15 years. You currently take Metformin XR 1000 mg daily and Gliclazide MR 60 mg daily.
- You’ve struggled with monitoring your blood sugar levels consistently. You often skip testing because it feels cumbersome and inconvenient.
- You occasionally forget to take your medication on busy or stressful days.
- You acknowledge your diet isn’t ideal. You rely frequently on ready-made meals, frozen dinners, or takeaways because it feels easier as you live alone.
- Exercise isn’t something you particularly enjoy or practice regularly, although you do attempt short walks a few times weekly.
Allergies and Other Medical Issues
- You are allergic to penicillin, which you recall causes an itchy rash all over your body.
- You have hypertension, managed with Perindopril 5 mg daily, and high cholesterol managed with Atorvastatin 40 mg daily.
- You haven’t had recent reviews or blood tests for your diabetes management, cholesterol levels, or kidney function within the past year.
- You stopped smoking around 10 years ago after strong advice from your previous GP.
Social and Emotional Background
- You retired three years ago after working many years as a truck driver.
- You lost your wife five years ago to cancer and have since felt lonely at times.
- You consume alcohol moderately, typically enjoying 3–4 beers weekly when socialising.
Your Current Concerns (Important points to raise spontaneously if not asked)
- You are extremely anxious about your ulcer worsening and the potential risk of infection leading to amputation, especially after witnessing your neighbour’s experience.
- You have wondered whether antibiotics might help, but worry about your penicillin allergy and the side effects of other medications.
- You’re curious about special dressings or other treatments you’ve read about online, and wonder if they would speed up healing.
- You feel guilty and concerned about your diabetes management and worry you haven’t done enough to prevent these complications.
- You’re keen to learn about practical, manageable changes to your diet and lifestyle that might help your diabetes control and prevent further complications.
Emotional Cues and Non-Verbal Behaviour
- Initially, appear visibly anxious and worried, fidgeting slightly or avoiding eye contact due to embarrassment about your condition.
- When discussing diabetes management and lifestyle, display a sense of regret or embarrassment, sighing or shaking your head subtly.
- Show obvious relief if the candidate reassures you that amputation can be avoided with proper management.
- If the candidate offers a clear plan or practical solutions, appear genuinely engaged and motivated.
Questions for the Candidate (Ask naturally in conversation when appropriate)
- “Doctor, is this ulcer serious? Could it lead to amputation like what happened to my neighbour?”
- “Do you think antibiotics or special dressings would help this heal faster?”
- “Is there anything specific I should be doing differently with managing my diabetes?”
- “Can ulcers like this be completely healed, or am I going to be stuck with this from now on?”
Clarifying Statements (Use if the candidate asks unrelated questions or details not covered by this script)
- For questions about sleep, mood or unrelated issues:
- “I haven’t had any particular problems with that.”
- “I think that’s been pretty okay for me recently.”
- For detailed family medical history:
- “My father had diabetes and died from a heart attack at 72. My mother died from a stroke at 80.”
- For general wellness or health-check questions:
- “Other than this foot, I’ve felt generally okay for my age.”
- For complex social inquiries beyond this scenario:
- “I get along alright; neighbours occasionally help out, but generally I manage fine.”
Closing the Interaction
- If the candidate provides a clear and reassuring management plan, express relief and gratitude, saying something like:
- “Thank you, doctor. I’m glad I came today. This has really eased my mind.”
- If the candidate appears uncertain or unclear, express mild ongoing concern, prompting them subtly:
- “So, just to make sure I’ve got it right, what exactly should I do next?”
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Task 1: Take a relevant history from the patient, including diabetes control and foot care practices.
Detailed Answer for Marking Guidance:
A competent candidate should demonstrate structured and comprehensive clinical information gathering. Key areas to address include:
History of Presenting Complaint:
- Duration and progression of the ulcer: established clearly as approximately six weeks, gradually enlarging.
- Associated symptoms: discharge, minimal pain due to neuropathy, no fever or systemic illness symptoms.
- Current wound care practices: pharmacy-bought dressings, antiseptic solutions, no professional care yet.
Diabetes Control:
- Duration and current medications: Diabetes diagnosed 15 years ago, on Metformin XR 1000mg and Gliclazide MR 60mg.
- Adherence: Inconsistent medication intake; difficulties in maintaining regular glucose monitoring.
- Recent diabetes management review: None in past year; unaware of current HbA1c level or diabetes complications.
- Diet and Lifestyle Factors: Reliance on convenience foods; sedentary lifestyle with minimal regular exercise.
Foot Care Practices:
- Footwear habits: Typically wears casual slip-on shoes, often without socks.
- Routine foot care: Limited self-inspection; no regular podiatry visits or professional foot examinations.
- Sensory status: Aware of reduced sensation in feet, as previously informed by GP.
Social History and Support:
- Lives alone after wife’s death; retired truck driver; occasional alcohol intake; ex-smoker, ceased ten years ago.
Patient Concerns and Understanding:
- Anxiety around potential infection and amputation, triggered by neighbour’s experience.
- Desire to understand seriousness and need for specific wound care and antibiotics.
The candidate should explore all the above areas sensitively, ensuring communication is patient-centred, empathic, and responsive to cues of anxiety and concern.
Task 2: Explain your differential diagnosis to the patient regarding the cause of their foot ulcer.
Detailed Answer for Marking Guidance:
The competent candidate should clearly and compassionately discuss possible causes of the foot ulcer, outlining their clinical reasoning:
- Diabetic neuropathic ulcer (most likely):
- Typically painless due to peripheral neuropathy from long-standing diabetes.
- Commonly on pressure points (e.g., soles of feet, toes), aligning with the patient’s current presentation.
- Often slow-healing due to poor blood sugar control and reduced tissue healing capacity.
- Peripheral vascular disease (possible contributing factor):
- Common in diabetics; poor circulation could exacerbate slow healing and risk of infection.
- Assessments like pulses and circulation tests (e.g., Ankle-Brachial Pressure Index – ABPI) may help evaluate this.
- Infection or cellulitis (needs consideration):
- Clear-yellow discharge noted; however, no redness, severe pain, systemic symptoms, or fever reported, suggesting infection not severe but requiring monitoring.
- Might necessitate wound swabs, laboratory tests, or imaging if clinical suspicion increases.
Clearly reassure the patient that, although serious, effective treatment and management strategies significantly reduce the risk of complications like amputation. Clarify that precise diagnosis and management planning rely on clinical examination and appropriate investigations.
Task 3: Provide appropriate management advice, including short-term treatment and longer-term preventive strategies.
Detailed Answer for Marking Guidance:
Management should reflect Australian guidelines (RACGP, Diabetes Australia), ensuring a holistic and patient-centred approach:
Short-Term Treatment Strategies:
- Wound care:
- Regular, professional wound dressings and debridement where required (community nurse or GP clinic initially, podiatrist later).
- Consideration of topical antiseptics or silver-based dressings; avoid penicillin-based antibiotics due to allergy.
- Education about signs of worsening infection (increasing redness, pain, discharge, fever) and instructions to return promptly if these occur.
- Diabetes review and optimisation:
- Arrange HbA1c testing, renal function, and lipid profile urgently.
- Consider optimisation of glycaemic control through medication adjustment or insulin initiation if required.
Longer-Term Preventive Strategies:
- Foot care education and professional podiatric care:
- Emphasis on daily self-inspection, appropriate footwear (comfortable, well-fitting shoes), avoidance of barefoot walking.
- Regular podiatry reviews (3-6 monthly).
- Lifestyle management:
- Nutritional advice from dietitian (diabetes-specific dietary plan, convenience meal alternatives).
- Gradual implementation of an exercise routine appropriate for diabetic and cardiovascular health.
- Regular medical monitoring:
- Routine GP visits (minimum 3-monthly), regular diabetes complication screening (eyes, kidneys, cardiovascular assessments).
- Psychosocial support:
- Acknowledging isolation and providing referrals to local diabetes support groups, mental health supports if required.
The candidate should clearly communicate these strategies with sensitivity and empathy, ensuring patient understanding, motivation, and comfort with the management plan.
SUMMARY OF A COMPETENT ANSWER
- Conducts a comprehensive clinical history including diabetes management, ulcer progression, and social circumstances.
- Clearly explains a rational differential diagnosis (neuropathic ulcer, peripheral vascular disease, infection) with reasoning.
- Provides an effective, holistic management plan (short-term wound care and infection management, long-term diabetic control, preventive foot care, lifestyle modification, psychosocial support).
- Demonstrates effective and empathic patient-centred communication, addressing patient’s ideas, concerns, and expectations.
PITFALLS
- Incomplete history: Neglecting detailed diabetes management, social factors, or routine foot care practices.
- Lack of differential diagnosis explanation: Failing to discuss peripheral vascular disease or infection alongside neuropathy.
- Inadequate patient education: Not effectively communicating wound care instructions, signs of worsening infection, or long-term preventive strategies.
- Ignoring psychosocial elements: Overlooking patient’s anxiety, isolation, or social context in management planning.
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.
1.3 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation
2.1 Gather relevant and sufficient clinical information.
3. Diagnosis, Decision-Making and Reasoning
3.1 Make rational clinical decisions and diagnoses.
4. Clinical Management and Therapeutic Reasoning
4.1 Develop effective and appropriate management plans.
4.2 Implement safe and quality therapeutic strategies.
5. Preventive and Population Health
5.1 Implement preventive health measures.
6. Professionalism
6.1 Demonstrate respectful and ethical conduct.
7. General Practice Systems and Regulatory Requirements
7.1 Work effectively within the general practice system.
8. Procedural Skills
8.1 Provide basic wound care management.
9. Managing Uncertainty
9.1 Manage clinical uncertainty effectively.
10. Identifying and Managing the Patient with Significant Illness
10.1 Identify and manage patients with complex medical needs.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD