CCE-CBD-156

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis and how do you justify carpal tunnel syndrome as the leading diagnosis?

• Prompt: Discuss the reasoning for carpal tunnel syndrome diagnosis.
• Prompt: Identify other possible differentials (e.g., cervical radiculopathy, diabetic neuropathy, rheumatoid arthritis).

Q2. What further investigations would you consider and why?

• Prompt: Discuss the role of nerve conduction studies and other tests to rule out differentials.
• Prompt: Comment on imaging and laboratory investigations if relevant.

Q3. Outline your management plan for Emma, including both conservative and surgical options.

• Prompt: Discuss first-line conservative treatments.
• Prompt: Indications for referral to a surgeon.

Q4. How would you address Emma’s concerns regarding work and her fear of permanent nerve damage?

• Prompt: Explore patient education, reassurance, and shared decision-making.
• Prompt: Consider ergonomic adjustments and workplace recommendations.

Q5. What preventive and long-term strategies would you recommend for Emma?

• Prompt: Discuss weight management, glycaemic control, and hand exercises.
• Prompt: Outline preventive strategies to avoid progression or recurrence.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis and how do you justify carpal tunnel syndrome as the leading diagnosis?

Answer:

The leading diagnosis in this case is Carpal Tunnel Syndrome (CTS), which is supported by Emma’s clinical presentation and examination findings. CTS is a compressive neuropathy of the median nerve at the wrist. Emma reports classic symptoms: numbness, tingling, and pain in the thumb, index, and middle fingers, worse at night, and aggravated by repetitive activities like typing.

Key clinical features pointing towards CTS include:

• Nocturnal paresthesia and relief on shaking the hand (classic “flick sign”).
• Distribution of sensory loss along the median nerve territory.
• Positive Phalen’s test (symptom reproduction with wrist flexion).
• Positive Tinel’s sign over the carpal tunnel.
• Mild thenar muscle wasting, suggesting chronic compression.

Differential Diagnoses:

• Cervical radiculopathy (C6-C7): Typically associated with neck pain, radiation along the dermatome, and possible reflex changes. Unlikely in this case due to the absence of neck symptoms.
• Diabetic peripheral neuropathy: More commonly presents with bilateral, symmetrical symptoms in a “stocking-glove” distribution, and is generally not limited to the median nerve territory.
• Rheumatoid arthritis: Can cause median nerve compression but is usually associated with systemic symptoms and other joint involvement.
• Pronator teres syndrome: Compression of the median nerve more proximally, but typically has pain on resisted pronation and lacks nocturnal symptoms.
• Ulnar neuropathy: Would involve the ring and little fingers and hypothenar eminence.

Justification:

The history, examination findings, and risk factors (diabetes, obesity, repetitive hand movements at work) strongly suggest CTS as the most probable diagnosis. According to RACGP Guidelines and Therapeutic Guidelines, CTS is diagnosed primarily on clinical grounds, supported by provocative tests.

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Q2: What further investigations would you consider and why?

Answer:

Primary Investigation:

• Nerve Conduction Studies (NCS):
  • Gold standard for confirming CTS diagnosis.
  • Measures sensory and motor latency; delayed conduction across the carpal tunnel confirms diagnosis.
  • Also helps rule out other peripheral neuropathies or proximal median nerve entrapments.

Additional Investigations (if indicated):

• Electromyography (EMG):
  • Complements NCS in evaluating chronicity and denervation of thenar muscles.
• Ultrasound of the wrist:
  • May demonstrate an enlarged median nerve at the carpal tunnel; useful when NCS is inconclusive.
• Blood Tests:
  • HbA1c (already done) to assess diabetic control.
  • Thyroid function tests: hypothyroidism is a risk factor for CTS.
  • Rheumatoid factor/ANA: if inflammatory arthritis is suspected.

Imaging (only if atypical presentation or considering surgical referral):

• MRI wrist: Not routinely required but may be useful in complex cases.

Rationale:

• The purpose is to confirm the diagnosis, assess severity, and identify any other contributing systemic causes before determining management options.

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Q3: Outline your management plan for Emma, including both conservative and surgical options.

Answer:

Conservative Management (First-line):

1. Wrist Splinting:
   • Neutral position splint, especially worn at night.
   • Reduces nocturnal symptoms by preventing wrist flexion.
2. Activity Modification:
   • Ergonomic adjustments at work (keyboard, mouse, wrist support).
   • Frequent breaks from repetitive tasks.
3. Pharmacological Therapy:
   • NSAIDs (short term) for inflammation and pain (although evidence of efficacy is limited).
   • Consider corticosteroid injection into the carpal tunnel if symptoms persist (supported by Therapeutic Guidelines, Rheumatology).
4. Comorbidity Management:
   • Optimise diabetic control and encourage weight loss.
   • Address any underlying thyroid dysfunction if present.

Surgical Management (if conservative measures fail after 6–12 weeks or severe symptoms with muscle wasting):

• Referral to a hand surgeon for carpal tunnel release (open or endoscopic).
  • High success rate (>90%) for symptom resolution.

Shared decision-making is key, ensuring Emma understands the options and risks/benefits of each.

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Q4: How would you address Emma’s concerns regarding work and her fear of permanent nerve damage?

Answer:

Acknowledge and validate her concerns.

• Empathy: “I understand how this is impacting your work and quality of life.”

Educate about the condition:

• Explain that CTS is common and manageable, especially when addressed early.
• Highlight the reversible nature of symptoms if treated appropriately.
• Clarify that permanent damage is unlikely at this stage but can occur if neglected.

Reassure:

• Her current symptoms (mild wasting but preserved function) suggest she is at an early to moderate stage.
• Treatment options are effective.

Practical Work Advice:

• Discuss ergonomic workstation adjustments and frequent breaks.
• Provide a medical certificate if reduced duties are needed.
• Suggest a referral to an occupational therapist for workplace modifications.

Promote shared decision-making, allowing Emma to express preferences and participate in her care plan.

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Q5: What preventive and long-term strategies would you recommend for Emma?

Answer:

Lifestyle Modifications:

• Weight reduction through a balanced diet and regular exercise.
• Maintain optimal glycaemic control (target HbA1c ≤7%).
• Encourage regular hand exercises and stretching to improve flexibility and reduce strain.

Workplace Ergonomics:

• Proper wrist positioning, using ergonomic devices (keyboard, mouse).
• Encourage frequent rest breaks from repetitive tasks.

Ongoing Monitoring:

• Review symptom progression regularly (every 6–12 weeks).
• Monitor for signs of increasing weakness or muscle wasting—indicates need for specialist referral.

Education and Self-care:

• Encourage Emma to report any worsening of symptoms early.
• Provide information about CTS and diabetes management resources.

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SUMMARY OF A COMPETENT ANSWER

• Clear differential diagnosis with logical reasoning.
• Appropriate and targeted investigations (NCS, blood tests).
• Comprehensive management plan: conservative and surgical options.
• Empathy and reassurance regarding work and future health.
• Preventive strategies tailored to comorbidities (obesity, diabetes).

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PITFALLS

• Failure to identify and explain other differentials (e.g., cervical radiculopathy).
• Inadequate explanation of conservative management options.
• Omitting discussion about occupational factors and ergonomic advice.
• Neglecting to explore patient’s concerns and fears about permanent damage.
• Delaying referral when symptoms indicate nerve compromise.

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Therapeutic Guidelines, Rheumatology
• Australian Diabetes Society
• Carpal Tunnel Syndrome on AANEM Guidelines

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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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes and monitors therapies appropriately.

5. Preventive and Population Health

5.1 Provides care that includes health promotion and illness prevention activities.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Practices in accordance with relevant policies and guidelines.

8. Procedural Skills

8.1 Performs procedural skills safely.

9. Managing Uncertainty

9.1 Manages uncertainty in diagnosis and management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages the patient with potentially serious illness.

12. Rural Health Context (RH)

RH1.1 Provides comprehensive, evidence-based care appropriate to rural settings.

Competency at Fellowship Level

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