EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Mark’s symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What findings would suggest a deep or serious infection?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Mark’s condition?

• Prompt: What conservative and pharmacological treatments would you recommend?
• Prompt: When would surgical intervention be necessary?

Q4. Mark is worried about losing function in his finger. How would you counsel him?

• Prompt: How would you explain the risks of delayed treatment?
• Prompt: What follow-up strategies would you implement?

Q5. What preventive strategies can Mark implement to reduce his risk of future infections?

• Prompt: What role does diabetes control play?
• Prompt: How can hand hygiene and workplace safety be optimised?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Mark’s symptoms?

Mark’s most likely diagnosis is acute paronychia, given the erythema, fluctuance, and purulent drainage around the nail fold following a minor injury. His poorly controlled diabetes increases the risk of infection.

Key Differential Diagnoses:

1. Paronychia (most likely) – Tender, swollen, erythematous nail fold with pus; often due to Staphylococcus aureus.
2. Felon – Deep pulp space infection with severe throbbing pain and tense swelling.
3. Cellulitis – Diffuse erythema without localised fluctuation.
4. Septic Arthritis (Finger Joint) – Painful, swollen joint with restricted movement.
5. Flexor Tenosynovitis (Kanavel’s signs) – Pain on passive extension, fusiform swelling, tenderness along flexor tendon.

Further assessment will confirm the diagnosis and rule out deeper infections.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent intervention:

• Signs of deep space infection – Severe pain, tense swelling, dusky skin (suggests felon or necrotising infection).
• Flexor Tenosynovitis – Pain with passive extension, fusiform swelling.
• Systemic symptoms – Fever, rigors, malaise (concern for sepsis).
• Rapidly spreading erythema – Possible necrotising fasciitis.

Recommended Investigations (if red flags present):

• X-ray of the finger – If osteomyelitis or retained foreign body is suspected.
• Blood cultures, FBC, CRP – If systemic involvement is suspected.
• Wound swab for culture – If drainage is performed.

Prompt referral is needed if deep infections, extensive cellulitis, or systemic signs are present.

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Q3: How would you manage Mark’s condition?

Conservative Management (if mild infection):

• Warm saline soaks 3–4 times daily.
• Avoid nail-biting or further trauma.
• Good glycaemic control to aid healing.

Pharmacological Therapy:

• Oral antibiotics (if mild infection without abscess):
  • Flucloxacillin 500mg QID for 7 days (covers Staphylococcus aureus).
  • Cephalexin if penicillin allergy.
  • Trimethoprim-sulfamethoxazole or doxycycline if MRSA risk.

Procedural Management (if abscess present):

• Incision & drainage – Small scalpel incision or needle aspiration for pus release.
• Drain placement if necessary.

Follow-up Plan:

• Review in 48 hours.
• Escalate care if symptoms worsen or spread despite antibiotics.

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Q4: Mark is worried about losing function in his finger. How would you counsel him?

1. Acknowledge his concerns
   • “Finger infections can become serious if untreated, but early intervention prevents complications.”
2. Explain Disease Progression and Recovery
   • “Most paronychias resolve within 5–7 days with proper care.”
   • “Deep infections like felons or tenosynovitis require urgent treatment to prevent permanent stiffness.”
3. Emphasise Importance of Treatment Compliance
   • “Taking antibiotics as prescribed and following wound care instructions reduce the risk of complications.”
4. Provide Reassurance and Follow-up Plan
   • “If your symptoms worsen or the infection spreads, return immediately.”
   • “We will review in 48 hours to ensure improvement.”

Timely treatment ensures a full recovery with no lasting impairment.

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Q5: What preventive strategies can Mark implement to reduce his risk of future infections?

1. Optimise Diabetes Control:
   • Maintain HbA1c <7% to reduce infection risk and improve healing.
2. Hand Hygiene and Workplace Safety:
   • Wear protective gloves when working with wood or sharp tools.
   • Regular hand washing and wound care for minor cuts.
3. Avoid Risk Factors:
   • Stop nail-biting or picking at the cuticles.
   • Quit smoking – Improves circulation and wound healing.
4. Regular Skin and Nail Checks:
   • Inspect fingers for cuts, redness, or swelling.
   • Seek early treatment if an infection develops.

Preventing infections involves optimising health, improving hygiene, and early intervention.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing superficial vs deep infections.
• Identification of red flags for urgent referral and further investigations.
• Structured evidence-based management plan, including antibiotics, drainage, and wound care.
• Clear patient-centred counselling, addressing functional concerns and need for follow-up.
• Preventive strategies, focusing on diabetes control, hand hygiene, and workplace safety.

PITFALLS

• Failing to assess for deep infection, leading to missed flexor tenosynovitis or septic arthritis.
• Overprescribing antibiotics without drainage, leading to poor symptom resolution.
• Not considering diabetes control, which impacts infection healing.
• Inadequate follow-up, risking progression to deep infection.
• Ignoring workplace safety factors, leading to recurring injuries.

REFERENCES

• RACGP – RACGP Clinical Guidelines for Skin and Soft Tissue Infections
• GP Exams – Infected finger/toe

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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 Takes a thorough history to assess the onset, progression, and risk factors for infection.
1.2 Provides clear explanations of diagnosis, treatment, and potential complications.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic examination of the affected digit.
2.2 Identifies red flags suggesting deeper infection or systemic involvement.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common causes of digit infections.
3.2 Determines when further investigations or referral are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including conservative, pharmacological, and procedural options.
4.2 Identifies when surgical intervention is needed.

5. Preventive and Population Health

5.1 Provides education on proper wound care and infection prevention.

6. Professionalism

6.1 Demonstrates empathy when addressing patient concerns about pain and function.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for infected wounds.

9. Managing Uncertainty

9.1 Recognises when specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious complications such as flexor tenosynovitis, deep space infections, or osteomyelitis.

Competency at Fellowship Level

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