CASE INFORMATION

Case ID: PNP-001
Case Name: David Sullivan
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: N92 – Peripheral Neuritis/Neuropathy

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Demonstrates active listening and empathy. 1.4 Explains diagnosis and management in a patient-centred manner.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including sensory, motor, and autonomic symptoms. 2.2 Identifies red flags requiring further investigation.
3. Diagnosis, Decision-Making and Reasoning	3.1 Establishes a working diagnosis based on history and examination findings. 3.2 Differentiates between common causes of peripheral neuropathy.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.5 Provides pharmacological and non-pharmacological recommendations. 4.7 Uses shared decision-making to address patient concerns.
5. Preventive and Population Health	5.1 Addresses lifestyle factors and metabolic conditions contributing to neuropathy. 5.2 Provides education on foot care to prevent complications.
6. Professionalism	6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements	7.1 Documents history, investigations, and management plan appropriately.
9. Managing Uncertainty	9.3 Recognises when specialist referral is required.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies when neuropathy may indicate an underlying serious condition (e.g., diabetes, B12 deficiency, malignancy).

CASE FEATURES

Middle-aged male presenting with gradual onset numbness and tingling in the feet.
Concern about progression and risk of falls.
History of type 2 diabetes, poorly controlled.
Likely diabetic peripheral neuropathy but requires exclusion of other causes.
Patient unsure about need for further investigations and management options.

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 Sullivan, a 62-year-old retired mechanic, presents with a six-month history of numbness and tingling in both feet. The symptoms have gradually worsened and now extend up to his mid-calf. He also reports occasional burning pain at night and a feeling of “walking on cotton wool”.

He has type 2 diabetes diagnosed 10 years ago, but his blood sugar control has been inconsistent. His most recent HbA1c was 9.2% (77 mmol/mol). He takes metformin and gliclazide but admit to missing doses and having a poor diet with little exercise.

His observations today are:

BP: 138/85 mmHg
HR: 74 bpm, regular
BMI: 31 kg/m²

PATIENT RECORD SUMMARY

Patient Details

Name: David Sullivan
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Metformin 1000 mg BD
Gliclazide 60 mg OD

Past History

Type 2 diabetes mellitus – poor glycaemic control
Hypertension

Social History

Occupation: Retired mechanic
Alcohol: 2-3 beers per night
Smoking: Smoked for 20 years, quit 10 years ago

Family History

Father: Heart disease, type 2 diabetes
Mother: Stroke

Vaccination and Preventative Activities

Influenza vaccine – up to date

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 SCRIPTS

Opening Line

“Doctor, my feet have been feeling numb and tingly for a while now, and I’m worried it’s getting worse.”

General Information

You are a 62-year-old retired mechanic who has had type 2 diabetes for 10 years.
For the past six months, you’ve noticed numbness and tingling in both feet, which has gradually worsened.
Initially, it was just in your toes, but now the sensation extends up to your mid-calf.

Specific Information

(Only Provide If Asked)

Background Information

The numbness is constant, and at night, you sometimes experience a burning or prickling pain in your feet.
You feel like you are “walking on cotton wool”, and it makes you unsteady at times.
You have not fallen yet, but you have stumbled a couple of times when walking on uneven surfaces.
You are worried about losing sensation completely or not being able to walk properly in the future.

Symptoms

No sharp pain or shooting pain into the legs.
No weakness or muscle wasting in your legs.
No significant changes in your hands or arms—only the feet are affected.
No changes in bowel or bladder function.
No changes in vision or dizziness.

Red Flags (None Present)

No sudden onset or rapid worsening.
No history of trauma, recent infections, or fever.
No new back pain.
No incontinence or saddle anaesthesia (loss of sensation in the inner thighs or perineum).

Medical and Lifestyle Factors

You take metformin and gliclazide but often forget doses or eat irregularly.
Your blood sugar control has been poor, and you haven’t been checking your glucose levels regularly.
Your most recent HbA1c was 9.2% (77 mmol/mol).
You drink 2-3 beers most nights but don’t use recreational drugs.
You quit smoking 10 years ago, but you smoked for 20 years before that.
Your diet is not great—you eat a lot of processed foods and takeaway meals.
You don’t exercise regularly because of tiredness and leg discomfort.

Functional and Emotional Impact

You are worried about losing your ability to walk.
You feel frustrated that this is another complication of diabetes.
You are concerned about long-term disability and needing a walking aid.
You are starting to feel anxious about going outside alone because you worry about falling.
Your partner is concerned and has been nagging you to see a doctor for months.

Concerns & Expectations

You want to know what is causing this and whether it can be reversed.
You are wondering if this could be something more serious, like multiple sclerosis.
You are worried you might need a scan (MRI) or nerve tests.
You are not keen on taking strong painkillers unless necessary.
You want to know if lifestyle changes would help or if this is too late to fix.

Possible Questions for the Candidate

“Is this serious? Will I lose the ability to walk?”
“Is this from my diabetes? Can it be reversed?”
“Do I need an MRI or nerve tests?”
“Are there any treatments for this?”
“Should I change my diet or exercise more?”
“Is there anything I can take apart from painkillers?”
“Would seeing a specialist help?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains That This Is Likely Diabetic Neuropathy:

“So, does that mean I’ve done permanent damage to my nerves?”
“Can I stop this from getting worse?”

If the Candidate Recommends Lifestyle Changes:

“I know I should eat better, but will that really make a difference at this stage?”
“How much exercise should I be doing? I don’t want to make things worse.”

If the Candidate Suggests Medications:

“I don’t want to be on strong painkillers. Are there other options?”
“Will these medications fix the problem or just cover up the symptoms?”

If the Candidate Mentions Nerve Tests or MRI:

“How do you know I don’t need a scan? What if this is something worse?”

If the Candidate Talks About Foot Care and Prevention of Complications:

“I hadn’t thought much about checking my feet. What should I be looking for?”
“Do I need to see a podiatrist?”

Role-Playing Tips for the Candidate Assessment

You are worried but not panicked. You want clear answers and practical solutions.
You feel frustrated about your diabetes control but not defensive—you know you need to do better.
If the candidate dismisses your concerns, push back. Ask, “So you’re saying this isn’t serious? How do you know?”
If the candidate only talks about medications, show doubt. Say, “Are you sure there’s nothing else I can do to fix this?”
If the candidate is vague about prognosis, ask for specifics. “How long will this take to improve?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I feel a bit better knowing what’s going on. I’ll try to improve my sugar control and be more careful with my feet. Let’s see how things go over the next few weeks.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including sensory, motor, and autonomic symptoms.

The competent candidate should:

Engage the patient with empathy, ensuring a supportive and non-judgmental consultation.
Use open-ended questions to explore:
- Onset, duration, and progression of symptoms.
- Nature of the symptoms: numbness, tingling, burning pain, altered sensation.
- Distribution of symptoms: bilateral vs unilateral, proximal vs distal.
- Motor symptoms: weakness, muscle atrophy, difficulty walking, foot drop.
- Autonomic symptoms: dizziness, bowel or bladder dysfunction, erectile dysfunction.
Assess functional impact, including falls risk, difficulty walking, and balance issues.
Obtain a comprehensive medical history, particularly:
- Diabetes duration and control (HbA1c, medication adherence).
- Medication history, including metformin (B12 deficiency risk).
- Alcohol consumption (risk of alcohol-related neuropathy).
- Family history of neuropathies, diabetes, or autoimmune diseases.
Identify red flags such as sudden onset, rapid progression, or asymmetry, which may indicate a more serious neurological condition.

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

Explain that diabetic peripheral neuropathy is the most likely diagnosis, given:
- Chronic, progressive sensory loss in a stocking distribution.
- Longstanding, poorly controlled diabetes (HbA1c 9.2%).
Differentiate from other causes, including:
- Vitamin B12 deficiency – metformin use, fatigue, cognitive changes.
- Alcohol-related neuropathy – chronic alcohol use, gait instability.
- Chronic inflammatory demyelinating polyneuropathy (CIDP) – weakness, asymmetry.
- Other metabolic causes – hypothyroidism, renal failure.
Outline an initial management plan, including:
- Glycaemic control – optimising blood sugar levels to slow progression.
- Symptomatic treatment – options for neuropathic pain (e.g., pregabalin, duloxetine).
- Lifestyle modifications – weight management, alcohol reduction, exercise.
- Referral for allied health support, including podiatry and physiotherapy.
Explain the role of investigations, including:
- Fasting glucose and HbA1c (assess glycaemic control).
- Vitamin B12 levels (metformin-associated deficiency).
- Renal function, thyroid function tests (rule out metabolic causes).
- Nerve conduction studies (if atypical presentation or diagnostic uncertainty).

Task 3: Address the patient’s concerns about progression, falls risk, and long-term impact.

The competent candidate should:

Acknowledge the patient’s fears about mobility and independence.
Reassure that neuropathy progression can be slowed with good diabetes control.
Address falls risk, advising:
- Proper footwear to reduce injury risk.
- Podiatry referral for regular foot checks.
- Balance exercises and physiotherapy to improve stability.
Explain that while nerve damage cannot always be reversed, symptoms can be managed.
Provide realistic expectations about treatment:
- Pain relief can be achieved, but full sensation recovery is unlikely.
- Early intervention is key to preventing worsening symptoms.
Offer psychosocial support, considering the impact on mood and quality of life.

Task 4: Develop a comprehensive management plan, including investigations, lifestyle modifications, and pharmacological or non-pharmacological interventions.

The competent candidate should:

Optimise glycaemic control:
- Encourage dietary changes and regular exercise.
- Review and adjust diabetes medications if needed.
- Consider referral to a diabetes educator.
Manage neuropathic pain:
- First-line: duloxetine, pregabalin, or gabapentin.
- Second-line: tricyclic antidepressants (e.g., amitriptyline).
- Avoid opioids due to lack of long-term benefit.
Address contributing factors:
- Check and supplement B12 if deficient.
- Advise alcohol reduction if intake is significant.
Prevent complications:
- Podiatry referral for foot care.
- Physiotherapy for balance training.
- Encourage daily foot checks to prevent ulcers.
Arrange follow-up in 4-6 weeks to assess symptom progression and response to treatment.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, covering sensory, motor, and autonomic symptoms.
Identifies key risk factors, particularly diabetes and medication use.
Explains the most likely diagnosis (diabetic neuropathy) while ruling out serious differentials.
Provides a structured management plan, covering glycaemic control, pain management, and lifestyle interventions.
Addresses patient concerns, including falls risk, prognosis, and impact on daily life.
Uses shared decision-making, ensuring the patient is actively involved in treatment choices.
Provides clear follow-up, ensuring ongoing assessment and care.

PITFALLS

Failing to assess red flags (e.g., rapid progression, asymmetry, motor weakness).
Not considering alternative causes, such as B12 deficiency or alcohol-related neuropathy.
Over-investigating unnecessarily, such as ordering MRI or nerve conduction studies without clear indications.
Focusing solely on medications, without discussing glycaemic control and lifestyle factors.
Not addressing the patient’s concerns about falls and mobility, missing the opportunity for podiatry and physiotherapy referrals.
Neglecting long-term monitoring, failing to arrange appropriate follow-up.

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including sensory, motor, and autonomic symptoms.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and examination findings.
3.2 Differentiates between common causes of peripheral neuropathy.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides pharmacological and non-pharmacological recommendations.
4.7 Uses shared decision-making to address patient concerns.

Competency at Fellowship Level

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