CCE-CBD-161

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses and how would you confirm the most likely diagnosis?

• Prompt: Describe your clinical reasoning process
• Prompt: What further investigations would you order?

Q2. Outline your immediate management plan for George’s toe infection.

• Prompt: Include both pharmacological and non-pharmacological management
• Prompt: How would you address his diabetes control?

Q3. How would you counsel George on foot care and prevention of further diabetic foot complications?

• Prompt: Address his concerns about amputation
• Prompt: Discuss the role of the multidisciplinary team

Q4. What strategies would you use to support George’s ongoing diabetes management, particularly in a rural context?

• Prompt: Consider telehealth and allied health access
• Prompt: Address lifestyle factors

Q5. What are the potential complications if George’s condition is not managed appropriately?

• Prompt: How would you recognise and escalate care in case of deterioration?
• Prompt: What local referral pathways exist?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

---

Q1: What are your differential diagnoses and how would you confirm the most likely diagnosis?

Answer:

In George Mason’s case, the primary concern is his painful, swollen right big toe, accompanied by redness, warmth, and purulent discharge. Based on the history and examination, my differential diagnoses include:

1. Infected diabetic foot ulcer—most likely, given his history of diabetes, ulceration, and signs of infection.
2. Osteomyelitis—suggested by the chronicity (two weeks), elevated inflammatory markers, and risk factors (poor diabetes control).
3. Gouty arthritis—considering acute monoarthritis of the first MTP joint, but less likely given purulent discharge.
4. Cellulitis without ulceration—although there is clear ulceration in this case.
5. Traumatic injury leading to secondary infection—possible due to history of trauma (stubbed toe).

To confirm the most likely diagnosis, which I believe is an infected diabetic foot ulcer with potential osteomyelitis, I would:

• Order wound swab cultures (already done) to identify causative organisms.
• Request foot X-rays to look for periosteal reaction or bone destruction suggestive of osteomyelitis.
• If X-ray is inconclusive and clinical suspicion remains, consider MRI, which is more sensitive for early osteomyelitis.
• Review his vascular status, given peripheral arterial disease risk, using Ankle-Brachial Index (ABI) and possibly Doppler ultrasound.
• Conduct vascular examination—checking dorsalis pedis and posterior tibial pulses, capillary refill, and signs of peripheral arterial disease.

I would monitor for systemic signs of infection, including fevers, chills, and rising inflammatory markers, to rule out systemic sepsis.

Relevant guidelines include the NHMRC Australian Guidelines for Diabetic Foot Infections and Wound Management in Diabetes.

---

Q2: Outline your immediate management plan for George’s toe infection.

Answer:

The immediate management includes addressing the infection, optimising diabetes control, and preventing further complications.

1. Antibiotic Therapy:

• Empiric oral antibiotics, such as amoxicillin-clavulanate 875/125 mg BD, covering gram-positive and gram-negative organisms.
• If systemic signs or severe infection are present, hospital admission for IV antibiotics (e.g., flucloxacillin or vancomycin plus ceftriaxone).

2. Wound Care:

• Debridement (if appropriate and not contraindicated by vascular insufficiency).
• Regular wound dressing with sterile technique to manage exudate and promote healing.
• Ensure offloading with a pressure-relieving device or special footwear.

3. Diabetes Management:

• Optimise glycaemic control, possibly initiating insulin therapy for rapid control.
• Review current medications and adherence.

4. Multidisciplinary Approach:

• Referral to podiatrist for wound care and footwear advice.
• Consider vascular surgeon if perfusion is inadequate.
• Diabetes educator for glucose monitoring support.

5. Patient Education:

• Emphasise the importance of foot care, daily inspections, and early reporting of injuries.

---

Q3: How would you counsel George on foot care and prevention of further diabetic foot complications?

Answer:

1. Education on Daily Foot Care:

• Inspect feet daily for cuts, blisters, redness, or swelling.
• Wash feet daily with warm water, dry thoroughly, especially between toes.
• Apply moisturiser to prevent dryness but avoid between toes.

2. Nail and Skin Care:

• Cut nails straight across and file edges.
• Avoid barefoot walking; wear well-fitting, closed-toe shoes.

3. Manage Risk Factors:

• Emphasise glycaemic control and smoking cessation.
• Control blood pressure and lipids.

4. Regular Reviews:

• Six-monthly foot checks or sooner if higher risk.
• Annual vascular and neurological assessments.

5. Address His Fear of Amputation:

• Empathise with his concerns.
• Explain that early intervention and self-care significantly reduce the risk of amputation.
• Reinforce that teamwork between him and healthcare providers can prevent complications.

---

Q4: What strategies would you use to support George’s ongoing diabetes management, particularly in a rural context?

Answer:

1. Telehealth Services:

• Regular virtual consultations with his GP and diabetes educator.
• Access to podiatry via telehealth if face-to-face is limited.

2. Local Health Services:

• Link George with community nursing services for wound care.
• Explore rural health programs like the Integrated Team Care Program (ITC).

3. Medication Adherence:

• Simplify regimen if possible.
• Ensure medications are delivered or accessible.

4. Lifestyle Support:

• Discuss healthy eating within his rural context.
• Encourage physical activity, respecting mobility limitations.

5. Psychological Support:

• Address mental health concerns, especially isolation.
• Referral to a rural psychologist via telehealth if needed.

---

Q5: What are the potential complications if George’s condition is not managed appropriately?

Answer:

1. Local Complications:

• Progression to osteomyelitis.
• Gangrene and need for amputation.
• Chronic ulceration leading to non-healing wounds.

2. Systemic Complications:

• Sepsis, potentially life-threatening.
• Worsening diabetes control and associated complications.

Escalation of Care:

• Immediate referral to hospital if signs of systemic infection or critical limb ischaemia.
• Early involvement of vascular surgeon if arterial insufficiency is confirmed.

Local Referral Pathways:

• Rural hospital admission.
• Referral to high-risk foot services (if available in regional centres).
• Coordination with Aboriginal Controlled Community Health Organisations (ACCHOs) if relevant.

---

SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, considering diabetic foot ulcer and osteomyelitis.
• Immediate management includes antibiotics, wound care, glycaemic control, and multidisciplinary care.
• Patient education focused on self-care and prevention, addressing fears.
• Rural-specific diabetes management strategies including telehealth and community services.
• Awareness of potential complications and timely escalation and referrals.

---

PITFALLS

• Missing signs of osteomyelitis and delaying imaging.
• Inadequate wound care or failure to arrange podiatry referral.
• Not addressing glycaemic control, leading to delayed healing.
• Overlooking psychosocial factors, such as isolation and fear of amputation.
• Ignoring vascular assessment, missing peripheral arterial disease.

---

REFERENCES

• RACGP Diabetes Management Guidelines
• NHMRC Australian Guidelines for the Prevention and Management of Foot Complications in Diabetes
• Wounds Australia on Best Practice Guidelines for the Management of Diabetic Foot Ulcers
• Australian Government Department of Health on Telehealth Initiatives

---

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 findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Demonstrates diagnostic reasoning including managing differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements patient-centred management plans.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Demonstrates ethical behaviour and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Understands systems to ensure patient safety and quality care.

8. Procedural Skills

8.1 Performs common procedures in general practice.

9. Managing Uncertainty

9.1 Recognises and manages diagnostic uncertainty.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potentially life-threatening or serious conditions.

12. Rural Health Context (RH)

RH1.1 Provides care relevant to the rural context, including limited resources and referral pathways.

---

Competency at Fellowship Level

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