EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Michael’s symptoms?

• Prompt: How do you differentiate between neurodegenerative, inflammatory, and metabolic causes?
• Prompt: What red flags would indicate an urgent referral?

Q2. What further history and investigations would be useful in this case?

• Prompt: What features would suggest a motor neurone disease (MND) diagnosis?
• Prompt: What tests help confirm or exclude specific neurological conditions?

Q3. How would you explain the diagnosis and next steps to Michael?

• Prompt: How do you communicate concern while maintaining empathy?
• Prompt: How do you discuss the need for neurological referral and further testing?

Q4. Outline your management plan for Michael’s condition.

• Prompt: What is the role of a neurologist in diagnosis and management?
• Prompt: What multidisciplinary supports are relevant?

Q5. What preventive strategies should Michael follow for his long-term care?

• Prompt: How can he optimise function and maintain quality of life?
• Prompt: What supportive services are available for neurodegenerative diseases?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Michael’s symptoms?

A structured approach is required to differentiate between neurodegenerative, inflammatory, metabolic, and structural causes of progressive neurological symptoms.

• Neurodegenerative Causes (Most Likely in This Case):
  • Motor neurone disease (MND, including amyotrophic lateral sclerosis – ALS) – Progressive asymmetric weakness, fasciculations, brisk reflexes, bulbar symptoms, absence of sensory loss.
  • Parkinson’s disease variant – Slowness, rigidity, bradykinesia, possible subtle tremor.
• Inflammatory/Autoimmune Causes:
  • Multiple sclerosis (MS) – Focal neurological deficits, visual disturbances, sensory changes.
  • Chronic inflammatory demyelinating polyneuropathy (CIDP) – Slowly progressive weakness, areflexia, sensory involvement.
• Metabolic/Endocrine Causes:
  • B12 deficiency – Neuropathy, gait disturbance, cognitive impairment.
  • Hypothyroidism – Fatigue, weight gain, proximal muscle weakness.
• Structural and Other Causes (Must Exclude):
  • Cervical myelopathy – Spinal cord compression, upper motor neuron signs.
  • Brainstem tumour – Progressive bulbar symptoms, cranial nerve involvement.

A competent candidate prioritises MND as a leading differential while ensuring other causes are considered and excluded.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Symptom progression: Rate of decline, involvement of other muscle groups.
  • Bulbar symptoms: Speech, swallowing difficulty, choking episodes.
  • Autonomic dysfunction: Bowel/bladder control, postural dizziness.
  • Cognitive symptoms: Suggestive of frontotemporal involvement.
• Investigations:
  • Electromyography (EMG) and nerve conduction study (NCS) – Essential to confirm MND (widespread denervation without sensory loss).
  • MRI brain/spine – To exclude structural causes such as cervical myelopathy or tumour.
  • B12, folate, thyroid function, HbA1c – To assess for metabolic contributors.
  • Lumbar puncture (if inflammatory disease suspected) – MS or CIDP.

A competent candidate tailors investigations to confirm the diagnosis while ruling out treatable causes.

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Q3: How would you explain the diagnosis and next steps to Michael?

1. Acknowledge concerns:
   • “I understand that these symptoms have been worrying for you, and I appreciate your patience as we investigate further.”
2. Explain clinical findings:
   • “Your symptoms, particularly progressive weakness and muscle fasciculations, raise concern for a neurological condition affecting motor function.”
3. Discuss next steps and need for referral:
   • “To understand the cause, we need specialised tests including an EMG and MRI, and I will refer you to a neurologist for further assessment.”
4. Provide reassurance while acknowledging uncertainty:
   • “At this stage, we don’t have a confirmed diagnosis, but we are ensuring a thorough and prompt workup.”
5. Safety-net and support:
   • “If you experience difficulty swallowing, breathing issues, or worsening weakness, please seek urgent medical care.”

A competent candidate communicates clearly and empathetically, balancing medical information with patient-centred care.

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Q4: Outline your management plan for Michael’s condition.

1. Referral to Neurology for Diagnosis Confirmation:
   • Urgent referral if rapid progression or respiratory involvement.
   • Multidisciplinary team involvement – Speech therapy, physiotherapy, palliative care if needed.
2. Symptom Management and Supportive Care:
   • Physiotherapy and occupational therapy – Mobility aids, hand therapy.
   • Speech and swallow assessment – If bulbar symptoms worsen.
   • Respiratory function monitoring – Assess for nocturnal hypoventilation in MND.
3. Medications (if MND diagnosed):
   • Riluzole – Slows disease progression in ALS.
   • Baclofen or diazepam – For spasticity.
4. Psychosocial Support:
   • Counselling and support groups – MND Australia, NDIS planning.
   • Advance care planning discussion – If disease progression confirmed.

A competent candidate ensures early referral, symptom relief, and patient-centred care.

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Q5: What preventive strategies should Michael follow for his long-term care?

1. Optimising Function and Quality of Life:
   • Regular physiotherapy – Maintains mobility and reduces stiffness.
   • Speech therapy – Early strategies for communication if bulbar symptoms develop.
   • Dietitian referral – Nutritional optimisation, PEG discussion if required.
2. Multidisciplinary and Community Support:
   • NDIS and disability support – Ensuring access to home modifications and care assistance.
   • Psychological and social support – Counselling, peer support groups.
3. Monitoring and Early Intervention:
   • Regular neurological follow-ups – Tracking disease progression.
   • Palliative care involvement (if needed) – Early discussions about symptom relief and future planning.

A competent candidate takes a proactive, multidisciplinary approach to optimising patient function and well-being.

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SUMMARY OF A COMPETENT ANSWER

• Recognises MND as a likely diagnosis, while excluding treatable causes such as cervical myelopathy, inflammatory disorders, and metabolic conditions.
• Takes a structured neurological history, identifying progressive weakness, fasciculations, and bulbar symptoms.
• Orders appropriate investigations, including EMG, MRI, and metabolic screening.
• Communicates clearly and empathetically, ensuring the patient is informed and supported during diagnostic workup.
• Develops a comprehensive management plan, including neurology referral, multidisciplinary support, and symptom control.
• Provides long-term care strategies, focusing on optimising function, accessing disability support, and ensuring psychological well-being.

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PITFALLS

• Failing to recognise red flags, delaying urgent neurology referral.
• Not ordering EMG and MRI, leading to misdiagnosis or missed treatable conditions.
• Over-reassuring the patient without acknowledging seriousness, causing delayed preparation for progressive disease.
• Neglecting multidisciplinary support, missing early interventions that improve quality of life.
• Not discussing advance care planning early, resulting in future challenges in decision-making.

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REFERENCES

• RACGP – RACGP Guidelines on Neurological Disorders
• GP Exams – Neurological disease NOS

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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 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

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