DIABETIC NEUROPATHY

DAVID OMAS

52, MALE

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Intro: You are a taxi driver who is attending the GP clinic to discuss your symptoms with your GP. You are in hurry to get back to work as a taxi driver.

Opening Line: My feet has been burning, doctor. It is affecting my work.

You have painful burning feet at night for last 2 months, it has been getting worse gradually. It sometimes feels hot, you uncovers your feet or somtimes, let them hang out of the bed for relief

History only if asked:

You do not have cold feet
It is disturbing your sleep at lot. This has made you irritable and tired as a result of fatigue – has led to some arguments with partner. You have not fallen asleep when driving.
There is no back pain. No other areas of altered sensation. No muscle weakness.
Your symptoms are not worse with exercises (walking) and not relieved by resting.
You are otherwise well , your mood is fine.
You can’t afford to have time off, business has been recently very quiet with the economic downturn
You are aware that you have a diagnosis of Type 2 Diabetes for 8 years. You have been told that it could be better, you have tried diet changes, exercises in the past to control your diet.
Your diet is poor, you buy lots of take-away food. You do not have time for exericse due to long shifts.
You always attend your annual diabetic reviews.

No Known Drug Allergies
You know your medications: Ramipril 10mg a day, Metformin 750mg MR 1 a day, Atorvastatin 20mg a day.

Last annual review of diabetes in March – told that your DM control could be better and diet changes and exercise were advised to avoid blindness, kidney failure and amputation and not ofgetting heart attack and stroke. You have not made any lifestyle changes, as no real practical advice was given at the time and you are unsure how you might achieve them.

You had an annual foot review at the time – you were told that you had good pulses and good circulation but a few numb patches on your feet. You have no foot ulcers, some dry skin, no cracks or redness or swelling of the skin.

Social History:
You are married for 23 years, with 3 children, all in university. You have to take more shifts to make school fees payments. You have a sedentary lifestyle due to long shifts as a taxi driver. You do not smoke, only drinks occassionally.

Ideas – No idea as to cause ? might it be poor circulation

Concerns – lack of sleep impacting on relationship and job. If it is poor circulation might he/she loose his foot/job (as iterated by endless docs/NPs in the past at annual review)

Expectations – A tablet to cure your leg symptoms so you go back to work. You would be prefere tablets that cause does not sedation or had a risk of dependence because of your work. If offered a topical treatment you would prefer that to a potentially sedating tablet

How to react:
You will be very hesitant and worried if informed you have to contact DVLA

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

PMH: Type 2 Diabetes for 8 years
No Known Drug Allergies
Drug History: Ramipril 10mg a day, Metformin 750mg MR 1 a day, Atorvastatin 20mg a day

Medical Notes - Last few entries in records:

Due for Annual DM review - has no responded to second invitation.
DM annual rev March last year: compliant with meds. No side effects. BP at target, ACR normal. Cholesterol normal. BMI 35 (up from 32). Hba1c 60 mmol/l (54mmol at last review) – lifestyle changes advised. Already had foot check all normal. Uses glasses, reminded to have annual eye check. Annual recall set

1. Data Gathering, interpretation and diagnosis

Positive indicators

Interprets and uses doctors note appropriately.
Appropriate differential diagnoses and sifting questions e.g., spinal neuropathy, PVD, DM neuropathy from data and from hx
Ask about foot and risk assessment – dry skin, cracking, infection and ulcers
Arrives at the correct likely diagnosis of diabetic neuropathy
Explores lifestyle & changes since last review
Explores patient health understanding around diabetes

Negatives Indicators

Incomplete Medical History: The doctor overlooks asking specific questions about the patient's diabetes management, lifestyle factors, and adherence to medications, which could provide valuable insights into the underlying cause of the foot pain.
Limited Exploration of Symptoms: The doctor focuses solely on the patient's description of foot pain and does not inquire about associated symptoms, such as changes in sensation or any recent injuries or traumas to the feet.
Failure to Address Concerns: The doctor does not adequately address the patient's concerns about the potential impact of foot pain on their job as a taxi driver or provide reassurance regarding the prognosis and management of their condition.

2. Clinical Management and managing medical complexity

Positive Indicators

Explanation of neuropathy which makes sense of the management options. Risks detailed.
Neuropathy bloods
Arranges doctor's appointment for physical exam of feet to exclude PVD, etc
Foot care advice
Rx in line with current EBM (capsaicin cream, duloxetine/amitriptyline with possible future use of gabapentanoids but risk of dependence must be explained if discussed)
Side effects discussed and potential impact minimised
Offers informational resources around foot safety and lifestyle change services
Appropriate review and safety-netting.

Negative Indicators

Lack of Thorough Examination: The doctor fails to conduct a comprehensive examination of the patient's feet to assess for signs of neuropathy or other diabetic complications.
Limited Treatment Discussion: The doctor does not explore a wide range of treatment options for managing the patient's foot pain, potentially overlooking alternative therapies or interventions that could provide relief.
Delayed Referral to Specialist: The doctor hesitates in referring the patient to podiatry for a more detailed foot review, which may delay the diagnosis and appropriate management of any underlying foot problems.

3. Relating to Others

Positive indicators

Encourages patient contribution, give golden minute to patient.
Develops and mainains rapport
Shows genuine empathy
Follow cues offered.
Flexible and conversational approach
Interested in him as a person
Explanation makes sense to the patient
Achieves a shared management plan
Explains diagnosis senstively (BBN) and offer hope about treatment without giving false assurances.
Non-judgemental discussion about patient's BMI and lifestyle.

Negative Indicators:

Poor Empathy: The doctor appears clinical and detached, failing to convey empathy or understanding of the patient's discomfort and concerns about their foot pain.
Poor Communication: The doctor's communication style is one-sided, with minimal engagement or active listening to the patient's experiences and preferences for treatment.
Insensitive Approach: The doctor overlooks the patient's fatigue and irritability, attributing it solely to disrupted sleep, without considering the broader impact on the patient's quality of life and relationships.

These are the key issues in this clinical scenario.

Recognizes new diagnosis and complications of diabetes.
Exclude of other alternative diagnosis
Explores and acknowledges psycho-social and lifestyle factors.
Empowers the patient to understand the new diagnosis
Clinical management in line with NICE CKS and good medical practice.

1. Data Gathering, interpretation and diagnosis

Positive indicators

Interprets and uses doctors note appropriately.
Appropriate differential diagnoses and sifting questions e.g., spinal neuropathy, PVD, DM neuropathy from data and from hx
Ask about foot and risk assessment – dry skin, cracking, infection and ulcers
Arrives at the correct likely diagnosis of diabetic neuropathy
Explores lifestyle & changes since last review
Explores patient health understanding around diabetes

Negatives Indicators

Incomplete Medical History: The doctor overlooks asking specific questions about the patient's diabetes management, lifestyle factors, and adherence to medications, which could provide valuable insights into the underlying cause of the foot pain.
Limited Exploration of Symptoms: The doctor focuses solely on the patient's description of foot pain and does not inquire about associated symptoms, such as changes in sensation or any recent injuries or traumas to the feet.
Failure to Address Concerns: The doctor does not adequately address the patient's concerns about the potential impact of foot pain on their job as a taxi driver or provide reassurance regarding the prognosis and management of their condition.

2. Clinical Management and managing medical complexity

Positive Indicators

Explanation of neuropathy which makes sense of the management options. Risks detailed.
Neuropathy bloods
Arranges doctor's appointment for physical exam of feet to exclude PVD, etc
Foot care advice
Rx in line with current EBM (capsaicin cream, duloxetine/amitriptyline with possible future use of gabapentanoids but risk of dependence must be explained if discussed)
Side effects discussed and potential impact minimised
Offers informational resources around foot safety and lifestyle change services
Appropriate review and safety-netting.

Negative Indicators

Lack of Thorough Examination: The doctor fails to conduct a comprehensive examination of the patient's feet to assess for signs of neuropathy or other diabetic complications.
Limited Treatment Discussion: The doctor does not explore a wide range of treatment options for managing the patient's foot pain, potentially overlooking alternative therapies or interventions that could provide relief.
Delayed Referral to Specialist: The doctor hesitates in referring the patient to podiatry for a more detailed foot review, which may delay the diagnosis and appropriate management of any underlying foot problems.

3. Relating to Others

Positive indicators

Encourages patient contribution, give golden minute to patient.
Develops and mainains rapport
Shows genuine empathy
Follow cues offered.
Flexible and conversational approach
Interested in him as a person
Explanation makes sense to the patient
Achieves a shared management plan
Explains diagnosis senstively (BBN) and offer hope about treatment without giving false assurances.
Non-judgemental discussion about patient's BMI and lifestyle.

Negative Indicators:

Poor Empathy: The doctor appears clinical and detached, failing to convey empathy or understanding of the patient's discomfort and concerns about their foot pain.
Poor Communication: The doctor's communication style is one-sided, with minimal engagement or active listening to the patient's experiences and preferences for treatment.
Insensitive Approach: The doctor overlooks the patient's fatigue and irritability, attributing it solely to disrupted sleep, without considering the broader impact on the patient's quality of life and relationships.