CCE-CBD-196

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate multiple sclerosis from other neurological conditions?
• Prompt: What features would raise suspicion for MS?

Q2. What are your initial management steps?

• Prompt: What investigations are required at this stage?
• Prompt: When would you refer for neurology review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address her concerns about MS?
• Prompt: What is the role of MRI in diagnosing MS?

Q4. What preventive measures can help manage her symptoms and long-term health?

• Prompt: What lifestyle modifications can help with MS symptoms?
• Prompt: When should she seek further medical attention?

Q5. What are the red flags that would necessitate urgent referral or intervention?

• Prompt: What clinical features suggest a severe or progressive neurological condition?
• Prompt: How would you manage a patient presenting with an acute MS relapse?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Multiple sclerosis (MS) is a chronic autoimmune demyelinating disease of the central nervous system. It presents with relapsing-remitting or progressive neurological symptoms.

Differential Diagnoses:

1. Multiple Sclerosis (Most Likely Diagnosis)
   • Key features: Episodes of neurological dysfunction, optic neuritis, leg weakness, sensory changes.
   • Uhthoff’s phenomenon – Worsening symptoms with heat exposure.
   • Family history of MS.
2. Neuromyelitis Optica (NMO)
   • Key features: Bilateral optic neuritis, long spinal cord lesions on MRI.
   • Requires anti-aquaporin-4 antibody testing.
3. Cerebrovascular Disease (TIA/Stroke)
   • Key features: Acute onset, no remissions, usually vascular risk factors present.
4. B12 Deficiency or Peripheral Neuropathy
   • Key features: Subacute sensory deficits, posterior column involvement.
   • Check serum B12 levels.
5. Functional Neurological Disorder
   • Key features: Inconsistent examination findings, exacerbated by stress.

Most Likely Diagnosis:

• MS, given the relapsing symptoms, optic neuritis, leg weakness, and heat sensitivity.
• MRI with contrast is the key diagnostic test.

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Q2: What are your initial management steps?

Answer:

1. Confirm Diagnosis with Investigations

• MRI Brain & Spine (with contrast): Look for demyelinating plaques.
• Lumbar Puncture (LP): Oligoclonal bands suggest MS.
• Blood tests:
  • FBC, UECs, ESR/CRP – Rule out infections/inflammation.
  • B12, ANA, anti-aquaporin-4 antibodies – Rule out differentials.

2. Acute and Long-Term Management

• If acute relapse:
  • IV methylprednisolone (1g/day for 3–5 days) for symptom control.
• Chronic disease-modifying therapy (DMT):
  • Refer to neurology for immunomodulatory therapy (e.g., natalizumab, fingolimod).

3. Referral and Follow-Up

• Urgent neurology referral for MRI and further management.
• Follow-up in 4 weeks to review results and discuss ongoing care.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms are concerning for multiple sclerosis, a condition where the immune system attacks the nerves.”
• “We will confirm this with an MRI and blood tests.”

Treatment Plan:

• “If MS is confirmed, we can manage it with medications that reduce relapses.”
• “We will also treat symptoms and provide long-term support.“

Safety-Netting:

• “If you develop worsening vision loss, difficulty walking, or severe fatigue, seek urgent medical help.”
• “We will review you after your tests in 4 weeks to discuss results.”

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Q4: What preventive measures can help manage her symptoms and long-term health?

Answer:

• Lifestyle modifications:
  • Regular exercise and physiotherapy to maintain mobility.
  • Adequate rest to reduce fatigue.
• Diet and Vitamin Supplementation:
  • Vitamin D supplementation may reduce relapse risk.
• Stress and Symptom Management:
  • Avoid excessive heat (Uhthoff’s phenomenon).
  • Cognitive behavioural therapy (CBT) for coping strategies.
• Regular Neurology Follow-Up:
  • Monitor for relapses or progression of disability.

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Q5: What are the red flags that would necessitate urgent referral or intervention?

Answer:

• Severe or sudden neurological decline (e.g., inability to walk).
• Rapidly worsening vision (optic neuritis with central vision loss).
• Signs of myelitis (bilateral leg weakness, urinary retention, back pain).
• Refractory pain or spasticity needing urgent symptom control.

Management of Acute MS Relapse:

• Urgent neurology assessment.
• IV methylprednisolone (1g/day for 3–5 days).
• Plasma exchange if steroid-resistant relapse.

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SUMMARY OF A COMPETENT ANSWER

• Correctly differentiates MS from other neurological conditions.
• Identifies MRI and LP as key diagnostic tests.
• Recognises when to refer to neurology for disease-modifying therapy.
• Provides lifestyle advice and symptom management strategies.
• Identifies red flags requiring urgent escalation.

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PITFALLS

• Failing to recognise early signs of MS.
• Not ordering an MRI to confirm the diagnosis.
• Overlooking reversible causes (B12 deficiency, NMO, stroke).
• Not referring to neurology for specialist management.

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REFERENCES

• RACGP Guidelines – Neurological Conditions and Multiple Sclerosis
• GP Exams – Multiple Sclerosis

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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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to neurological symptoms.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between multiple sclerosis and other neurological conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including referral to neurology.
4.2 Recognises when urgent investigations or specialist review is required.

5. Preventive and Population Health

5.1 Provides education on symptom management and lifestyle modifications.

Competency at Fellowship Level

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