EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Thomas’s neck pain?

• Prompt: How do you differentiate between mechanical, inflammatory, and serious causes?
• Prompt: What red flags would indicate the need for urgent imaging or referral?

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

• Prompt: What risk factors increase suspicion for a more serious cause?
• Prompt: When would you consider ordering imaging or blood tests?

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

• Prompt: How do you reassure him about his concerns regarding arthritis and nerve compression?
• Prompt: What lifestyle modifications and conservative treatments would you recommend?

Q4. Outline your management plan for Thomas’s neck pain.

• Prompt: What conservative treatments are effective?
• Prompt: When would you refer him to physiotherapy or a specialist?

Q5. What preventive strategies should Thomas follow to reduce future neck pain episodes?

• Prompt: What ergonomic and exercise modifications are important?
• Prompt: When should he seek medical attention for worsening symptoms?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Thomas’s neck pain?

A structured approach is required to differentiate between mechanical, inflammatory, and serious causes of neck pain.

• Mechanical Causes (Most Likely in This Case):
  • Cervical strain or myofascial pain – Gradual onset, worsens with prolonged sitting, improves with movement.
  • Cervical spondylosis (degenerative changes) – Age-related degeneration, stiffness, possible mild nerve impingement.
• Inflammatory and Autoimmune Causes:
  • Rheumatoid arthritis – Morning stiffness >30 minutes, multiple joint involvement, family history.
  • Spondyloarthropathy (e.g., ankylosing spondylitis) – Young onset, progressive stiffness, better with movement, sacroiliac involvement.
• Serious or Red Flag Conditions (Must Exclude):
  • Cervical radiculopathy – Nerve root compression causing arm pain, numbness, weakness, positive Spurling’s test.
  • Cervical myelopathy – Spinal cord compression with gait disturbance, hyperreflexia, loss of fine motor skills.
  • Infection (osteomyelitis, meningitis, retropharyngeal abscess) – Fever, systemic symptoms, neck rigidity.
  • Malignancy (metastases, lymphoma) – Weight loss, night sweats, persistent pain despite rest.

A competent candidate prioritises mechanical causes while screening for serious pathology.

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

• Further History:
  • Onset and progression: Acute vs chronic, triggering factors.
  • Neurological symptoms: Arm numbness, weakness, gait disturbance (suggests radiculopathy or myelopathy).
  • Morning stiffness duration: >30 minutes suggests inflammatory arthritis.
  • Red flags: Weight loss, fever, night sweats, trauma history.
• Investigations (if indicated):
  • X-ray cervical spine – If concern for spondylosis, degenerative changes.
  • MRI cervical spine – If neurological symptoms present (radiculopathy, myelopathy).
  • Blood tests:
    • ESR/CRP (inflammation).
    • Rheumatoid factor, anti-CCP (if inflammatory arthritis suspected).
    • FBC, LFTs (if malignancy or systemic illness suspected).

A competent candidate tailors investigations based on clinical suspicion and red flags.

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

1. Acknowledge concerns:
   • “I understand that ongoing neck pain can be frustrating, and you’re concerned about arthritis or nerve issues.”
2. Explain likely cause:
   • “Your symptoms suggest mechanical neck pain, likely due to muscle tension and posture-related strain.”
3. Reassure but safety-net:
   • “There are no red flags suggesting a serious condition, and your neurological exam is normal.”
   • “If you develop numbness, weakness, or worsening pain, let me know immediately.”
4. Discuss treatment and self-care:
   • “We can improve this with postural adjustments, stretching, and targeted exercises.”
5. Plan follow-up:
   • “I’ll see you again in 4–6 weeks to check progress and adjust management if needed.”

A competent candidate provides a clear explanation, reassures, and ensures appropriate follow-up.

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Q4: Outline your management plan for Thomas’s neck pain.

1. Non-Pharmacological Management (First-Line):
   • Physiotherapy referral – Postural training, manual therapy, strengthening exercises.
   • Ergonomic adjustments – Optimise desk setup, use a supportive chair, frequent breaks.
   • Heat therapy, stretching – Can help reduce muscle tightness.
2. Pharmacological Management (If Needed for Pain Relief):
   • Paracetamol or NSAIDs (e.g., ibuprofen 400 mg PRN).
   • Consider muscle relaxants (e.g., diazepam short-term) if muscle spasm present.
3. Referral and Follow-Up:
   • Review in 4–6 weeks.
   • MRI and specialist referral if neurological symptoms develop.

A competent candidate prioritises conservative management, reserves imaging for specific indications, and ensures follow-up.

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Q5: What preventive strategies should Thomas follow to reduce future neck pain episodes?

1. Postural and Ergonomic Modifications:
   • Maintain good posture – Keep screen at eye level, avoid prolonged flexion.
   • Use an adjustable chair and keyboard to reduce strain.
2. Regular Exercise and Strengthening:
   • Neck and shoulder exercises – Prevents stiffness and muscle imbalance.
   • Core strengthening – Supports spinal alignment.
3. Lifestyle Adjustments:
   • Avoid prolonged sitting – Take breaks every 30–60 minutes.
   • Ensure a supportive pillow and mattress.
4. When to Seek Medical Attention:
   • New neurological symptoms (numbness, weakness, difficulty walking).
   • Persistent or worsening pain despite conservative management.

A competent candidate tailors prevention to the patient’s lifestyle and occupational factors.

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SUMMARY OF A COMPETENT ANSWER

• Recognises mechanical neck pain as the likely diagnosis, while ruling out red flags.
• Takes a structured history, screening for inflammatory and serious causes.
• Orders targeted investigations, reserving imaging for neurological or red flag symptoms.
• Explains the condition clearly, addressing concerns about arthritis and nerve compression.
• Implements an evidence-based management plan, including physiotherapy, ergonomics, and pain relief.
• Advises on preventive strategies, ensuring long-term neck health and posture awareness.

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PITFALLS

• Failing to recognise red flag symptoms, leading to missed serious pathology.
• Over-reliance on imaging, exposing the patient to unnecessary investigations.
• Not addressing ergonomic and postural issues, missing an opportunity for preventive care.
• Neglecting follow-up planning, leading to poor symptom control and patient anxiety.
• Not considering inflammatory arthritis in a patient with a relevant family history, delaying diagnosis and treatment.

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REFERENCES

• RACGP – RACGP Guidelines on Neck Pain and Radiculopathy
• GP Exams – Neck symptom/complaint

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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