Case ID: B6-TOX-001
Case Name: Sarah Lawson
Age: 45 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T92 (Poisoning by Vitamins), N99 (Neurological Disorder, Other), A84 (Adverse Effect of Medication)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a patient-centred approach 1.2 Uses active listening and questioning skills 1.4 Demonstrates empathy and sensitivity
2. Clinical Information Gathering and Interpretation	2.1 Gathers a relevant and focused history 2.2 Identifies red flags and risk factors
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates appropriate differential diagnoses 3.3 Considers common and serious conditions
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Uses shared decision-making in treatment options
5. Preventive and Population Health	5.1 Provides education on supplement use and toxicity risks 5.3 Discusses strategies to prevent self-medication errors
6. Professionalism	6.2 Demonstrates a professional and non-judgmental approach
7. General Practice Systems and Regulatory Requirements	7.2 Understands reporting requirements for supplement-related adverse effects
8. Procedural Skills	8.1 Recognises when laboratory tests (e.g., serum B6 levels, nerve conduction studies) are needed
9. Managing Uncertainty	9.1 Identifies when specialist referral (e.g., neurologist, toxicologist) is warranted
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises neurological complications requiring intervention

CASE FEATURES

Considering alternative diagnoses and when to refer for specialist input.
Middle-aged woman presenting with neurological symptoms.
Chronic high-dose vitamin B6 supplementation leading to toxicity.
Symptoms of sensory neuropathy (numbness, tingling, burning sensations in extremities).
Exploring supplement use and patient’s understanding of safety.
Providing education on supplement risks and appropriate dosing.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Formulate a differential diagnosis and justify your reasoning.
Develop a management plan.
Address the patient’s concerns.

SCENARIO

Sarah Lawson, a 45-year-old marketing manager, presents with progressive numbness, tingling, and burning pain in her hands and feet over the past three months. She initially thought it was due to working long hours at her desk, but the symptoms have gradually worsened. She also reports occasional difficulty with balance and fine motor tasks, such as buttoning her shirt.

She denies muscle weakness, headaches, or vision changes.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Lawson
Age: 45 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Vitamin B6 (200mg daily) – self-prescribed for the past 9 months
Multivitamin (contains additional B6 in small amounts)

Past Medical History

No chronic illnesses
No diabetes or autoimmune conditions

Family History

No known neurological disorders
No family history of vitamin deficiencies

Social History

Works in a high-stress office job, spends long hours on a computer.
Non-smoker, drinks socially (1-2 drinks per week).
Exercises irregularly due to work commitments.

Vaccination and Preventative Activities

Up to date with routine vaccinations.

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line:

“Doctor, my hands and feet have been tingling and burning for a while now. It’s getting worse, and I’m starting to worry.”

General Information

(Freely Given if Asked Open-Ended Questions):

Your symptoms started gradually about three months ago and have been getting worse over time.
The sensations are mostly in your hands and feet, but sometimes you feel them going up your legs.
It feels like a constant tingling or pins-and-needles sensation that is sometimes a bit painful.

Specific Information

(Only Given If Asked Directly):

Background Information

You feel it more at night or when you’ve been sitting at your desk for a long time.
You sometimes struggle with fine motor tasks, like buttoning your shirt, holding a pen, or typing for long periods.
You have felt a bit unsteady on your feet, but you haven’t fallen.
You first thought it was just from sitting too much at work, but it hasn’t improved even when you take breaks.

Neurological Symptoms:

No muscle weakness—your strength feels normal.
No headaches, dizziness, or vision problems.
No difficulty swallowing or slurred speech.
No recent injuries or trauma to your back or limbs.
No bowel or bladder issues—you’ve had normal function in that area.

Supplement Use:

You started taking vitamin B6 nine months ago after reading online that it could help with energy and brain function.
You have been taking 200mg per day, thinking it was a safe and beneficial dose.
You also take a daily multivitamin, which has some extra B6 in it.
You have not seen a doctor about this before and were unaware there could be risks with vitamins.

Other Medications and Health History:

You do not take any prescription medications.
You do not have diabetes, thyroid problems, or autoimmune conditions.
You have never had neurological issues before.
You have no history of alcohol abuse or toxic exposures (e.g., heavy metals, industrial chemicals).

Concerns About Symptoms and Prognosis:

You are worried that your symptoms might be permanent.
You want to know if there is a treatment to reverse the damage.
You are frustrated because you thought supplements were always safe and can’t believe this could happen from a vitamin.
You are concerned about whether your nerves will fully recover or if this will affect your work and daily activities long-term.
You want to know if you should take other supplements to help with nerve healing.
You feel embarrassed and upset that you may have caused this by taking a supplement.

Emotional and Behavioural Cues:

You appear frustrated and anxious, fidgeting with your hands and rubbing your feet at times.
If the doctor explains B6 toxicity, you look surprised and slightly embarrassed.
If the doctor reassures you that symptoms can improve over time, you seem relieved but still a bit nervous.
If the doctor criticises supplement use too harshly, you become defensive and say “But it’s a vitamin—how can it be bad for me?”
If the doctor explains that symptoms may take months to improve, you appear disheartened and worried about long-term effects.

Potential Questions for the Candidate:

“Could this be permanent nerve damage?”
“Do I need any tests or scans?”
“Should I stop taking all my vitamins?”
“Is there any treatment to make my nerves heal faster?”
“How long will it take for my symptoms to go away?”
“Why isn’t this more widely known? I had no idea this could happen.”
“Should I see a neurologist?”
“Can I take anything to help my recovery?”
“Do I need to worry about any other vitamins I’m taking?”
“Could this have caused any other damage to my body?”

Guidance for Role-Player Responses:

If the candidate explains B6 toxicity clearly, you should appear surprised and ask why this information isn’t widely known.
If the candidate reassures you that symptoms usually improve over time, you should seem relieved but still a bit anxious.
If the candidate suggests stopping all supplements, you should ask whether that includes your multivitamin and if any vitamins are actually safe.
If the candidate mentions a long recovery time, you should appear disappointed and ask if anything can speed up the healing process.
If the candidate suggests referral to a neurologist, you should ask if that’s really necessary and what they would do differently.
If the candidate dismisses your concerns too quickly, you should push back and ask if permanent nerve damage is possible.

Key Learning Points for the Candidate:

This case evaluates the candidate’s ability to:

Recognise vitamin B6 toxicity as the cause of the patient’s symptoms.
Take a comprehensive neurological history and differentiate from other causes of neuropathy.
Provide a clear and structured management plan, including immediate cessation of B6 supplements and monitoring for improvement.
Reassure the patient about symptom reversibility, while setting realistic expectations for recovery (which may take months).
Educate the patient on the risks of excessive supplement use in a non-judgmental manner.
Recognise when further investigations (e.g., nerve conduction studies) or specialist referral is warranted.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on neurological symptoms, supplement use, and medication history.

The competent candidate should:

Explore the neurological symptoms, including:
- Onset, duration, and progression (symptoms started three months ago, gradually worsening).
- Character and distribution (tingling, burning, numbness in hands and feet, spreading up the legs).
- Impact on function (difficulty with fine motor tasks and balance issues).
Clarify red flag symptoms, ruling out:
- Muscle weakness, bladder/bowel dysfunction, vision changes, dizziness, or headaches.
Assess supplement use:
- Exact dose and duration of vitamin B6 use (200mg/day for 9 months).
- Other supplements or medications (multivitamin containing additional B6).
- Reason for use (self-prescribed for brain function and energy).
Exclude alternative causes of neuropathy, such as:
- Diabetes (check for history of high blood sugar).
- Alcohol use (rule out alcohol-related neuropathy).
- Autoimmune diseases (ask about joint pain, rashes, or other systemic symptoms).
Elicit patient concerns:
- Fear of permanent nerve damage.
- Desire for symptom relief and treatment options.

Task 2: Formulate a differential diagnosis and justify your reasoning.

The competent candidate should:

Most likely diagnosis: Vitamin B6 toxicity causing sensory neuropathy.
Consider alternative diagnoses:
- Diabetic neuropathy – but patient has no diabetes history.
- Alcohol-related neuropathy – non-drinker.
- Autoimmune neuropathy (Guillain-Barré syndrome, lupus) – no recent infections or systemic symptoms.
- Heavy metal toxicity – unlikely as patient has no industrial exposure.
Justify investigations:
- Serum B6 levels (if available, though not always necessary).
- Nerve conduction studies (if symptoms persist after stopping B6).
- Blood tests (FBC, UEC, LFTs, HbA1c, thyroid function) to rule out other causes.

Task 3: Develop a management plan, including discontinuation of supplements, symptom management, and follow-up.

The competent candidate should:

Immediate intervention:
- Stop vitamin B6 supplementation immediately.
- Check all other supplements for hidden B6 content.
Symptom management:
- Reassure that symptoms often improve but may take months to resolve.
- Recommend pain relief for burning sensations (paracetamol or low-dose gabapentin if severe).
- Encourage physiotherapy or occupational therapy if function is impaired.
Follow-up plan:
- Review in 4-6 weeks to monitor symptom improvement.
- Refer to a neurologist if symptoms persist beyond 6 months.
- Consider nerve conduction studies if significant impairment remains.

Task 4: Address the patient’s concerns, particularly regarding reversibility of symptoms and safe supplement use.

The competent candidate should:

Acknowledge the patient’s frustration and concern.
Provide education on supplement risks:
- Explain that high-dose B6 can cause nerve damage.
- Discuss safe upper limits (≤50mg/day for long-term use).
- Advise against self-medicating with high-dose vitamins without medical supervision.
Discuss prognosis:
- Symptoms often improve within months, but full recovery varies.
- Some mild residual symptoms may persist in severe cases.
Reassure the patient:
- No evidence of permanent structural damage.
- Stopping B6 early increases the chance of full recovery.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive neurological history, assessing symptoms, duration, and impact.
Identifies high-dose vitamin B6 supplementation as the likely cause.
Excludes alternative causes of neuropathy, considering diabetes, autoimmune, and toxic causes.
Provides an evidence-based management plan, including stopping B6, symptom control, and follow-up.
Addresses patient concerns empathetically, setting realistic expectations for recovery.
Educates on supplement safety, preventing recurrence and unnecessary self-medication.

PITFALLS

Failing to ask about supplement use, missing the underlying cause.
Not considering alternative causes of neuropathy, leading to misdiagnosis.
Overlooking red flag symptoms, such as progressive weakness or bowel/bladder involvement.
Giving unrealistic expectations, suggesting symptoms will resolve immediately.
Not advising follow-up, missing persistent or worsening cases needing neurology referral.
Failing to educate on supplement safety, risking recurrent or preventable toxicity.

REFERENCES

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 a relevant and focused history.
2.2 Identifies red flags and risk factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates appropriate differential diagnoses.
3.3 Considers common and serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.2 Uses shared decision-making in treatment options.

5. Preventive and Population Health

5.1 Provides education on supplement use and toxicity risks.
5.3 Discusses strategies to prevent self-medication errors.

6. Professionalism

6.2 Demonstrates a professional and non-judgmental approach.

7. General Practice Systems and Regulatory Requirements

7.2 Understands reporting requirements for supplement-related adverse effects.

8. Procedural Skills

8.1 Recognises when laboratory tests (e.g., serum B6 levels, nerve conduction studies) are needed.

9. Managing Uncertainty

9.1 Identifies when specialist referral (e.g., neurologist, toxicologist) is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises neurological complications requiring intervention.

Competency at Fellowship Level

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