CASE INFORMATION

Case ID: 2024-EMD-01
Case Name: David Harrison
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: T99 (Limited function/disability endocrine/metabolic)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communication is appropriate to the person and sociocultural context. 1.2 Engages the patient to gather information about symptoms, concerns, expectations, and impact on daily life. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Obtains relevant medical history and functional impact. 2.2 Identifies key clinical signs and symptoms associated with metabolic dysfunction.
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates an appropriate differential diagnosis. 3.2 Identifies potential complications related to metabolic disease and functional impairment.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe, patient-centred management plan. 4.2 Engages in shared decision-making for ongoing care.
5. Preventive and Population Health	5.1 Provides appropriate lifestyle modification advice to prevent deterioration.
6. Professionalism	6.1 Demonstrates ethical and patient-centred care.
7. General Practice Systems and Regulatory Requirements	7.1 Understands and utilises appropriate disability and support systems.
9. Managing Uncertainty	9.1 Recognises when referral to specialist care is warranted.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies complications and provides appropriate interventions.

CASE FEATURES

Potential eligibility for NDIS or disability support.
52-year-old male with type 2 diabetes and obesity-related disability.
Progressive difficulty with mobility, neuropathy, and reduced ability to work.
Concerns about employment, financial stress, and long-term prognosis.

INSTRUCTIONS

You have 15 minutes to complete this consultation.

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 reference.

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

David Harrison is a 52-year-old man with type 2 diabetes, obesity (BMI 38), and peripheral neuropathy. He presents today feeling frustrated and discouraged about his deteriorating mobility and increasing difficulty performing his job as a warehouse supervisor.

He reports frequent foot pain, numbness, and difficulty walking long distances, which has led him to reduce his work hours. He is also experiencing fatigue, low mood, and concerns about his future ability to work.

PATIENT RECORD SUMMARY

Patient Details

Name: David Harrison
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Metformin 1000 mg BD
Dulaglutide 1.5 mg weekly
Atorvastatin 40 mg nocte
Ramipril 5 mg daily

Past History

Type 2 diabetes mellitus (diagnosed 8 years ago)
Hypertension
Peripheral neuropathy
Hypercholesterolaemia
Obesity (BMI 38)

Social History

Works as a warehouse supervisor, struggling with physical tasks.

Family History

Father: Myocardial infarction at age 60.
Mother: Type 2 diabetes, osteoarthritis.

Smoking

Alcohol

Occasional, 2–3 standard drinks per week.

Vaccination and Preventative Activities

Up to date with flu and COVID-19 vaccines.

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, I just don’t know how much longer I can keep doing this. My feet hurt all the time, I can’t walk far, and I’m scared I won’t be able to work soon.”

General Information

You were diagnosed with type 2 diabetes 8 years ago, but controlling your blood sugar and weight has been difficult.
Over the past 2 years, you’ve noticed worsening numbness and pain in your feet, which is making work harder.
You feel tired and sluggish all the time, even after a full night’s sleep.
You’ve cut back your work hours because of pain and fatigue, and you’re worried you won’t be able to work much longer.

Specific Information

(Only disclose if asked)

Background Information

Your job as a warehouse supervisor involves standing, walking, and lifting, which has become increasingly difficult.
Your wife is worried about finances, and you feel guilty about not being able to provide as much.
You wonder if you qualify for disability support, but you don’t know how the process works.
You’ve been feeling frustrated and low, but you haven’t seen a psychologist or discussed this with anyone.

Symptoms and Functional Impact:

The pain and numbness in your feet started about 2 years ago but has gotten much worse in the past 6 months.
You struggle with stairs and feel like you’re tripping more often.
The pain is worse at night, sometimes keeping you awake.
Your hands feel fine, but you sometimes drop things.
You’re worried about losing your ability to walk in the future.

Pain and Medication:

You take paracetamol when the pain is bad, but it doesn’t help much.
You haven’t tried stronger painkillers, but you’re open to discussing options.
You haven’t seen a podiatrist or diabetes specialist in a long time.

Diet and Exercise:

You don’t exercise much because it hurts to walk.
You eat a lot of processed foods and soft drinks, but you know you should do better.
Your wife cooks healthy meals, but you often snack on junk food.

Medication and Compliance:

You take metformin and dulaglutide but sometimes miss doses.
You don’t always check your blood sugar levels.
You haven’t had an HbA1c test in over a year.

Social and Emotional Concerns:

Your wife is supportive but stressed about your health and finances.
You feel guilty about reducing your work hours.
You haven’t told your boss about how bad things are because you fear losing your job.
You feel down and frustrated but wouldn’t say you’re depressed.
You wonder if losing weight would help, but you don’t know where to start.

Patient’s Concerns and Questions

“Is there anything else I can do to help my feet?”
- You’ve heard of nerve pain medications, but you don’t know if they work.
- You’re willing to try physiotherapy if it might help.
“Will I qualify for disability support?”
- You’ve heard about NDIS and Centrelink benefits, but you don’t understand them.
- You’re not sure if your condition is severe enough to qualify.
“Am I going to lose my ability to walk?”
- You’re scared of getting worse and ending up in a wheelchair.
- You want to know if there’s anything that can stop this from getting worse.
“Should I see a specialist for my diabetes?”
- You haven’t seen an endocrinologist in years.
- You don’t know if a neurologist or podiatrist would help.

Emotional Cues and Body Language

Frustrated and discouraged when discussing work and finances.
Concerned and uncertain when talking about disability benefits.
Sad and defeated when describing the impact on daily life.
Hopeful but hesitant when discussing treatment options.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, focusing on the impact of their metabolic condition on daily function

The competent candidate should:

Use open-ended questions to explore the patient’s symptoms, including pain, numbness, mobility issues, and fatigue.
Assess functional limitations, particularly how the symptoms affect the patient’s ability to work and perform daily activities.
Explore medication adherence and diabetes management, identifying any barriers to compliance.
Inquire about mental health, including low mood, stress, and concerns about disability or financial strain.
Assess diet and lifestyle, including physical activity and weight management strategies.
Identify patient expectations and concerns, particularly regarding disease progression, treatment options, and potential for disability benefits.

Task 2: Explain the likely diagnosis and contributing factors to the patient’s symptoms

The competent candidate should:

Explain that the patient’s symptoms are consistent with diabetic peripheral neuropathy, a common complication of longstanding type 2 diabetes.
Discuss how poor glycaemic control, obesity, and lifestyle factors contribute to nerve damage.
Address the impact of peripheral neuropathy on mobility and quality of life, including fall risk and potential disease progression.
Explain that pain and numbness may worsen without intervention, but lifestyle changes and medications can improve symptoms.
Reassure the patient that with better diabetes control and symptom management, functional decline can be slowed or prevented.

Task 3: Develop a management plan addressing pain, function, and diabetes control

The competent candidate should:

Offer pain management options, including neuropathic pain medications (e.g., pregabalin, duloxetine).
Recommend referral to a podiatrist for foot care, orthotics, and ulcer prevention.
Encourage physical activity modification, suggesting low-impact exercises (e.g., swimming, cycling).
Discuss dietary changes and weight management to improve diabetes control and reduce symptoms.
Arrange a diabetes care plan with a multidisciplinary team (dietitian, diabetes educator, endocrinologist if needed).
Review and optimise diabetes medications, considering GLP-1 receptor agonists if weight loss is a goal.
Address mental health, providing psychological support or referral if the patient is struggling emotionally.

Task 4: Provide information about disability benefits and workplace support

The competent candidate should:

Explain workplace modifications that might allow the patient to continue working (e.g., sitting tasks, reduced hours).
Discuss the NDIS and Centrelink disability support options, guiding the patient on the application process.
Provide a medical certificate or referral if needed for workplace accommodations or support services.

SUMMARY OF A COMPETENT ANSWER

Elicits a thorough history, including pain, function, medication adherence, and emotional impact.
Explains the diagnosis in simple terms, linking diabetes to neuropathy and functional decline.
Provides a clear management plan, addressing pain, mobility, weight, and diabetes control.
Discusses disability benefits and work accommodations, offering guidance on available support.
Shows empathy and reassurance, validating the patient’s concerns while promoting proactive management.

PITFALLS

Failing to explore functional impact – Not recognising how symptoms are affecting daily life and work.
Overlooking mental health concerns – Missing signs of distress, guilt, or financial anxiety.
Not discussing lifestyle modifications – Focusing only on medications without addressing weight, diet, and exercise.
Not considering specialist referrals – Ignoring the role of podiatry, endocrinology, or physiotherapy in management.
Giving false reassurance – Minimising the risk of disease progression without emphasising the importance of diabetes control.

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, 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 Gathers relevant clinical history and information systematically.
2.2 Interprets clinical findings to formulate a working diagnosis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses appropriate clinical reasoning to reach a diagnosis.
3.3 Recognises and explains potential complications.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan addressing symptoms, disease progression, and patient concerns.
4.2 Prescribes and explains treatment options, including medications and lifestyle changes.

5. Preventive and Population Health

5.1 Incorporates preventive care into the consultation (e.g., weight management, foot care).

6. Professionalism

6.2 Provides patient-centred care that is compassionate and supportive.

7. General Practice Systems and Regulatory Requirements

7.1 Demonstrates awareness of disability support and referral processes.

8. Procedural Skills

8.1 Identifies the need for diabetic foot screening and appropriate physical assessments.

9. Managing Uncertainty

9.1 Addresses the patient’s concerns about the future while promoting an optimistic management approach.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises the progressive nature of diabetic complications and acts accordingly.

Competency at Fellowship Level

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