EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for John’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 symptoms or findings would suggest an urgent or serious neuropathy?
• Prompt: What initial investigations would you consider?

Q3. How would you manage John’s condition?

• Prompt: What lifestyle modifications and non-pharmacological options would you recommend?
• Prompt: When would pharmacological therapy or referral be appropriate?

Q4. John is worried about permanent nerve damage. How would you counsel him?

• Prompt: How would you explain the progression of peripheral neuropathy?
• Prompt: What follow-up strategies would you implement?

Q5. What preventive strategies can John implement to slow progression and manage symptoms?

• Prompt: What lifestyle modifications can help?
• Prompt: What role does foot care play in diabetic neuropathy?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

John’s most likely diagnosis is diabetic peripheral neuropathy (DPN) given his long-standing type 2 diabetes, poor glycaemic control, and progressive stocking distribution of sensory loss.

Key Differential Diagnoses:

1. Diabetic Peripheral Neuropathy – Most common cause in diabetes, presenting with distal sensory loss, absent ankle reflexes, and burning pain.
2. Alcohol-related Neuropathy – Chronic alcohol intake can lead to thiamine deficiency and nerve damage.
3. Vitamin Deficiencies (B12, B1, E) – Consider in those with malabsorption, vegetarian diet, or chronic alcohol use.
4. Medication-induced Neuropathy – Statins, chemotherapy drugs, or antiretrovirals can contribute.
5. Chronic Kidney Disease (Uraemic Neuropathy) – If renal function is impaired.
6. Neurological Disorders (e.g., Guillain-Barré Syndrome, CIDP, Multiple Sclerosis) – Consider if rapidly progressive or asymmetric.

Further investigations will guide diagnosis and management.

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

Red flags requiring urgent referral or additional tests:

• Acute onset or rapidly progressive neuropathy – Suggests Guillain-Barré Syndrome, vasculitis, or malignancy.
• Asymmetry or focal deficits – Consider mononeuropathy, radiculopathy, or stroke.
• Severe weakness, foot drop, or autonomic dysfunction (postural hypotension, gastroparesis).
• Painful neuropathy resistant to standard treatment.

Recommended Investigations:

• HbA1c – Assess glycaemic control.
• B12, folate, thiamine (B1) – Identify deficiencies.
• Renal function tests – Screen for uraemia.
• TSH & Free T4 – Rule out hypothyroidism.
• Nerve conduction studies (if uncertain diagnosis or atypical features).

If there are red flags, referral to neurology or endocrinology may be warranted.

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Q3: How would you manage John’s condition?

Lifestyle and Non-Pharmacological Management:

• Optimise diabetes control – Aim for HbA1c <7.0% to slow progression.
• Reduce alcohol intake – Encourage limiting to ≤2 standard drinks/day.
• Smoking cessation – Smoking worsens microvascular complications.
• Exercise and physiotherapy – Improves balance, mobility, and neuropathic pain.

Pharmacological Therapy (if needed):

• First-line: Pregabalin (start 75mg nocte) or duloxetine (30mg daily).
• Alternatives: Gabapentin, amitriptyline (if no contraindications).
• Topical therapy: Capsaicin cream or lidocaine patches for localised pain.

Follow-up & Monitoring:

• Regular foot checks – Prevent ulceration.
• Monitor medication response and side effects.
• Refer to neurology if symptoms progress despite treatment.

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Q4: John is worried about permanent nerve damage. How would you counsel him?

1. Acknowledge his concerns
   • “Peripheral neuropathy can be managed effectively, though nerve recovery depends on addressing underlying causes.”
2. Explain Disease Progression
   • “Good blood sugar control and lifestyle changes can slow or prevent worsening.”
   • “Nerve pain can improve with appropriate treatment over time.”
3. Discuss Treatment Goals
   • “Our focus is on symptom relief, preventing complications, and improving function.”
   • “Medications can help with pain but won’t reverse existing nerve damage.”
4. Encourage Active Management & Follow-up
   • “Regular diabetes check-ups, foot care, and physiotherapy are key.”
   • “If symptoms worsen, we may adjust treatment or refer for specialist care.”

Providing realistic expectations while focusing on symptom control and long-term care is essential.

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Q5: What preventive strategies can John implement to slow progression and manage symptoms?

1. Optimise Diabetes Control
   • Aim for HbA1c <7%, avoid large glucose fluctuations.
2. Lifestyle Modifications
   • Reduce alcohol and quit smoking – Improves nerve health.
   • Increase physical activity – Improves circulation and nerve function.
3. Regular Foot Care
   • Daily foot checks for ulcers, dry skin, infections.
   • Podiatry review every 6–12 months.
4. Medication Review & Adjustment
   • Avoid neuropathy-worsening drugs where possible (e.g., excessive statins).
5. Early Intervention for Symptoms
   • Seek medical review if pain worsens or new symptoms develop.

Preventing progression relies on a proactive, multidisciplinary approach.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, considering diabetes, alcohol, vitamin deficiencies, medications, and neurological disorders.
• Identification of red flags, recognising when urgent referral or further tests are needed.
• Structured evidence-based management plan, incorporating glycaemic control, lifestyle changes, neuropathic pain treatment, and physiotherapy.
• Clear patient-centred counselling, addressing long-term prognosis and symptom management.
• Preventive strategies, focusing on foot care, medication review, and early intervention.

PITFALLS

• Failing to assess red flags, missing Guillain-Barré, spinal cord disease, or vasculitis.
• Not optimising diabetes control, leading to progression of neuropathy.
• Overlooking alcohol as a contributing factor, delaying effective treatment.
• Prescribing pain relief without addressing underlying causes.
• Not advising regular foot care, increasing risk of ulcers and amputation.

REFERENCES

• RACGP – RACGP Guidelines for Diabetes Management
• GP Exams – Peripheral neuritis/neuropathy

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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 structured neurological history to assess symptoms and functional impact.
1.2 Provides clear explanations about diagnosis, investigations, and management.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic neurological examination including sensory, motor, and reflex assessment.
2.2 Identifies red flags that warrant urgent investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common causes of peripheral neuropathy.
3.2 Determines when further investigations are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an individualised management plan based on underlying cause.
4.2 Considers pharmacological and non-pharmacological options for neuropathic pain.

5. Preventive and Population Health

5.1 Provides education on lifestyle modifications and prevention strategies for peripheral neuropathy.

6. Professionalism

6.1 Demonstrates empathy and ensures patient-centred care when discussing chronic symptoms.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for chronic neuropathy management.

9. Managing Uncertainty

9.1 Recognises when specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious causes of neuropathy requiring urgent intervention.

Competency at Fellowship Level

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