CASE INFORMATION

Case ID: CTS-001
Case Name: John Matthews
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L92 (Neuropathy/CTS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages patient to explore symptoms, concerns, and expectations 1.2 Provides clear and structured explanations 1.3 Uses active listening to identify patient’s concerns 1.4 Demonstrates empathy and reassurance
2. Clinical Information Gathering and Interpretation	2.1 Conducts a focused history to assess severity and impact of symptoms 2.2 Identifies risk factors such as occupational exposure, comorbidities (diabetes, obesity)
3. Diagnosis, Decision-Making and Reasoning	3.1 Forms a differential diagnosis for hand pain and numbness 3.2 Recognises red flags that may suggest alternative diagnoses (e.g., cervical radiculopathy)
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate management plan 4.2 Provides guidance on conservative treatments (e.g., wrist splinting, NSAIDs, ergonomic modifications) 4.3 Recognises indications for referral (e.g., severe cases requiring surgical intervention)
5. Preventive and Population Health	5.1 Educates on lifestyle modifications to prevent worsening of symptoms (e.g., weight management, ergonomic adjustments)
6. Professionalism	6.1 Maintains confidentiality and professional conduct
7. General Practice Systems and Regulatory Requirements	7.1 Follows Medicare guidelines for referrals and imaging requests
8. Procedural Skills	8.1 Performs Phalen’s test, Tinel’s sign, and median nerve compression test
9. Managing Uncertainty	9.1 Balances conservative management with early recognition of when referral is needed
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies progressive symptoms that warrant urgent specialist review

CASE FEATURES

Middle-aged male with gradual onset of wrist pain and numbness
Occupation as a construction worker, high risk for repetitive strain injuries
Night-time symptoms affecting sleep quality
Concerns about impact on work and long-term function
Potential contributing factors (obesity, diabetes, smoking)

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.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

John Matthews, a 47-year-old construction worker, presents to your general practice with a 3-month history of numbness, tingling, and pain in his right hand. He reports that symptoms are worse at night, often waking him up. The pain sometimes extends up his forearm. He has noticed weaker grip strength and occasionally drops tools at work. He denies any significant neck pain but occasionally experiences mild stiffness.

PATIENT RECORD SUMMARY

Patient Details

Name: John Matthews
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Metformin 500 mg BD

Past History

Type 2 diabetes (diagnosed 5 years ago)
Obesity (BMI 32)

Social History

Works full-time as a construction worker

Family History

Father: Type 2 diabetes
Mother: Osteoarthritis

Smoking

10 cigarettes/day for 20 years

Alcohol

4-6 standard drinks/week

Vaccination and Preventative Activities

Flu vaccine: Up to date
COVID-19 vaccines: Completed

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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, my right hand has been going numb at night, and it’s getting worse. I’m worried about work.”

General Information

(Freely given if the candidate asks open-ended questions like “Can you tell me more about that?”)

The symptoms started about three months ago.
It began as occasional tingling and numbness in the thumb, index, and middle fingers.
Over the last few weeks, the numbness has worsened and is now waking me up at night.
I have to shake my hand or move my wrist to make the numbness go away.

Specific Information

(Only given when the candidate asks direct questions)

Background Information

The pain sometimes radiates up my forearm.
My grip strength feels weaker—I’ve noticed I’m dropping tools more often at work.
I use power tools every day—a lot of repetitive work, hammering, and using a jackhammer.
I sometimes feel a bit of stiffness in my neck, but no severe neck pain.
It’s affecting my sleep and making me more tired during the day.
I haven’t seen anyone about this before—I thought it would go away.
It’s getting to the point where I can’t ignore it anymore.

Occupational Impact

I work as a construction worker, and I use my hands constantly.
I do a lot of gripping, lifting, and vibrating tool use (e.g., drills, hammers, jackhammers).
My boss has noticed me struggling and asked if I’m okay.
I’m worried that if I can’t do my job properly, I might lose work.
I haven’t told my employer about it yet—I don’t want them to think I’m not fit for the job.
I feel frustrated and anxious because I can’t afford to take time off work.

Medical History & Risk Factors

I was diagnosed with type 2 diabetes five years ago.
My diabetes is mostly stable, but I don’t always check my blood sugars.
I know that diabetes can cause nerve problems, but I thought that mostly affected the feet.
I smoke 10 cigarettes a day, have been smoking since my early 20s.
I know I could lose some weight—I’m about 95kg, and I’m 175cm tall (BMI 31).
I don’t exercise much outside of work—I’m usually too tired after a long shift.
My dad has diabetes, and my mum has arthritis.

Current Management & Self-Treatment

I’ve been taking paracetamol, but it doesn’t seem to do much.
I massage my hand when it goes numb—it helps a little.
I tried wearing a wristband, but it didn’t make a difference.
I’ve never used a wrist splint—do they work?
I haven’t taken any time off work yet, but I’m starting to struggle.
I haven’t had any scans or tests done—do I need one?

Patient’s Concerns & Expectations

“Is this serious? Could it be something worse?”
“Do I need to have surgery? I’ve heard of people getting operations for this.”
“Is this from my job? If I keep working like this, will it get worse?”
“Will I have to stop working? I really can’t afford time off.”
“Are there exercises or treatments I can do at home?”
“If I lose weight or stop smoking, will that help?”
“Should I be worried about diabetes affecting my nerves?”
“Do I need a scan or an X-ray?”

Emotional Responses & Body Language

Appears worried and frustrated—anxious about the future of his job.
Looks uncomfortable, occasionally shakes his right hand while talking.
Frowns when discussing sleep problems, rubbing his eyes occasionally.
Leans forward when talking about work concerns, making eye contact.
Shows mild frustration when discussing pain management, sighing.
Nods when given information, but if unclear, asks “What does that mean?”

Final Patient Expectations

Wants clear advice on whether he can keep working.
Hopes for a treatment plan that doesn’t involve surgery.
Would consider lifestyle changes (like quitting smoking or losing weight) if it will help.
Wants to know if he needs to see a specialist.
Prefers conservative treatment first before considering drastic measures.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history regarding the patient’s symptoms, occupational impact, and risk factors.

The competent candidate should:

Establish the onset, duration, and progression of symptoms, including numbness, tingling, and pain in the thumb, index, and middle fingers.
Identify aggravating and relieving factors—such as repetitive hand use, night-time symptoms, and relief from shaking the hand.
Ask about functional impact, including difficulty gripping tools and interference with work.
Explore occupational risk factors, such as vibrating tool use, repetitive wrist movements, and prolonged gripping.
Assess general health and comorbidities, particularly diabetes, obesity, and smoking, which increase the risk of median nerve dysfunction.
Check for differential diagnoses, including cervical radiculopathy, peripheral neuropathy, and arthritis, by asking about neck pain, other limb symptoms, and joint issues.
Consider red flags such as bilateral symptoms, muscle wasting, or systemic signs that might indicate more severe pathology.
Address patient concerns, particularly job security and fears about surgery.

Task 2: Explain your differential diagnosis to the patient, ensuring clarity and addressing concerns.

The competent candidate should:

Explain that carpal tunnel syndrome (CTS) is the most likely diagnosis, given the numbness, tingling, and weakness in a median nerve distribution, worsening at night.
Discuss work-related factors that may have contributed, such as vibration, repetitive strain, and hand positioning.
Mention other possible causes, including:
- Cervical radiculopathy (if there were neck pain or symptoms extending beyond the hand).
- Diabetic peripheral neuropathy (if symptoms were bilateral or affecting other nerves).
- Rheumatoid arthritis or osteoarthritis (if there was joint pain and stiffness).
Address patient concerns, reassuring that many cases improve with conservative treatment and that surgery is not always needed.

Task 3: Discuss the management plan, including conservative treatment options, work modifications, and follow-up care.

The competent candidate should:

Recommend wrist splinting at night, which has strong evidence for symptom relief in mild-to-moderate CTS.
Suggest NSAIDs for pain relief, though they are not curative.
Advise reducing repetitive hand strain, including:
- Ergonomic adjustments (e.g., using padded gloves, alternating tasks).
- Taking breaks from repetitive movements.
Provide exercises and stretches to reduce pressure on the median nerve.
Address modifiable risk factors, such as:
- Smoking cessation, which may improve nerve healing.
- Optimising diabetes control to prevent worsening neuropathy.
- Weight loss, if applicable, to reduce median nerve compression.
Explain that steroid injections or surgical referral may be considered if symptoms persist or worsen.
Arrange follow-up in 4-6 weeks to assess progress and consider referral if symptoms remain disabling.

Task 4: Outline indications for referral to a specialist if necessary.

The competent candidate should:

Recognise that most mild-to-moderate CTS cases improve with conservative measures.
Identify indications for specialist referral, including:
- Failure of conservative treatment after 6-12 weeks.
- Severe symptoms (persistent numbness, constant pain, weakness affecting daily activities).
- Signs of nerve damage (e.g., muscle wasting of the thenar eminence, significant weakness).
- Diagnostic uncertainty, such as atypical symptoms or suspected underlying neurological disease.
Discuss nerve conduction studies as a diagnostic tool before surgery.
Reassure that surgery (carpal tunnel release) is effective but only necessary for severe or persistent cases.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history including symptom progression, occupational impact, and risk factors.
Explains the differential diagnosis clearly, emphasising CTS while ruling out other conditions.
Develops a structured management plan including conservative measures, lifestyle modifications, and work adjustments.
Identifies appropriate referral criteria, ensuring specialist involvement when necessary.
Uses patient-centred communication, addressing concerns about work, treatment options, and prognosis.

PITFALLS

Failing to ask about occupational risk factors, which are critical in this case.
Not considering differential diagnoses, particularly cervical radiculopathy or diabetic neuropathy.
Jumping to surgical management too soon, without attempting conservative measures first.
Neglecting patient concerns about job security and fear of losing function.
Not addressing lifestyle factors, such as smoking, diabetes, and obesity, which can worsen neuropathy.

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

Competency Domains Assessed

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts hypothesis-driven history-taking, including occupational factors and comorbidities.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses appropriate reasoning to form a differential diagnosis and rule out serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, prioritising non-invasive treatment initially.

5. Preventive and Population Health

5.1 Provides education on risk factor modification (smoking, obesity, diabetes).

6. Professionalism

6.1 Maintains a patient-centred and empathetic approach, considering work implications.

7. General Practice Systems and Regulatory Requirements

7.1 Refers appropriately when conservative management fails.

8. Procedural Skills

8.1 Explains and performs relevant physical tests (Phalen’s, Tinel’s sign).

9. Managing Uncertainty

9.1 Recognises when conservative management is appropriate vs. when referral is needed.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flags requiring urgent referral (thenar atrophy, severe weakness).

Competency at Fellowship Level

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