Burning Feet At Night and Numbness On His Last Foot Check — Free SCA Practice Case
Diabetic man with burning feet at night and numbness on his last foot check
Station Timer
12:00
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
12:00
Golden MinuteMaterials for Candidate
Please review before starting the consultation
Patient Profile
Full Name
Trevor Higgins
Age
66 years
Consultation Type
VideoAge
66
Situation
Video Consultation.
Reason for Encounter
"I've got this burning in my feet, especially at night. And at my last foot check the nurse said I'd lost some feeling in my feet — that worried me."
Medical Records
- ●PMH: Type 2 diabetes (8 years). Hypertension.
- ●Medications: Metformin 1 g BD. Ramipril 5 mg OD. Atorvastatin 20 mg ON.
- ●Allergies: NKDA.
- ●Recent results: HbA1c 53 mmol/mol (improved, with weight loss). B12 normal. eGFR normal. QRISK >10%.
- ●Foot check (3 months ago): Reduced sensation to monofilament (loss of protective sensation); pulses documented as present.
Patient Script
For the friend playing the patient role
Character Overview: You are Trevor, a 66-year-old retired electrician with type 2 diabetes. You have burning, tingling discomfort in both feet, worse at night, disturbing your sleep. At your last foot check the nurse said you had lost some feeling, which frightened you (you have heard of diabetics losing toes). You have actually done well recently — lost weight and improved your diabetes control. You are motivated and want to protect your feet and get the burning under control.
Opening Sentence: "Hi Doctor. For a few months now I've had this burning, tingling feeling in both feet — it's worst at night and it's keeping me awake. And at my last diabetic foot check, the nurse told me I'd lost some feeling in my feet. That's really worried me — I don't want to end up losing a toe like my old workmate did."
History if Asked (Data Gathering Phase)
- ●The symptoms: "Burning and tingling in both feet, like pins and needles but painful. Worse at night in bed — the sheets on my feet set it off. It's affecting my sleep."
- ●The numbness: "The nurse used that little filament thing and said I'd lost feeling in parts of my feet. I hadn't really noticed myself, which is the scary part."
- ●Diabetes: "I've actually done well — lost weight, my last number was 53, down from higher. I take my metformin."
- ●Walking (if asked): "My walking's alright. My feet don't cramp up or force me to stop when I walk, and the pain's more at rest and at night than when I'm moving." (No claudication.)
- ●Feet appearance: "No colour changes, no ulcers or sores that I've seen, no swelling."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.
- ●Ideas: Trevor understands this is something to do with his diabetes and nerves, and is worried it is the start of serious foot problems. "I think it's my diabetes affecting the nerves. I'm scared it's the start of losing my feet."
- ●Concerns: His dominant concerns are losing sensation/his feet (amputation) and the sleep-disturbing burning pain. "I'm frightened about my feet — my workmate lost a toe. And the burning at night is wearing me down."
- ●Expectations: He wants the burning treated and to know how to protect his feet. "I want something for the burning, and to know what I do to keep my feet safe."
If Asked — Neuropathy, Vascular, and Foot-Risk Screen
The patient answers these only when directly asked.
- ●If asked about the distribution (both feet, 'stocking' pattern): "Both feet, up to about the ankles — like socks."
- ●If asked about claudication (calf pain on walking, relieved by rest): "No — my legs don't cramp when I walk, and stopping doesn't relieve it. It's more a night-time burning." (Distinguishes from vascular claudication.)
- ●If asked about foot ulcers, wounds, or infections: "No sores or ulcers that I've noticed — but with the numbness I worry I might not feel one."
- ●If asked about foot deformity or previous foot problems: "No deformities, no previous foot problems."
- ●If asked about colour change, coldness, or swelling: "No colour change, feet aren't cold, no swelling."
- ●If asked about alcohol (neuropathy cause): "A couple of beers at weekends, not excessive."
- ●If asked about B12/other neuropathy causes: "The nurse said my B12 was normal."
- ●If asked about erectile/autonomic or other neuropathy symptoms: "Nothing else I've noticed."
- ●If asked about footwear and foot care: "Just normal shoes. I don't really do anything special for my feet."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains this is diabetic peripheral neuropathy: "So the burning and the numbness are both the diabetes affecting my nerves? Can it be reversed?" (The tested point is explaining diabetic peripheral neuropathy and setting realistic expectations.)
- ●If the Doctor offers a neuropathic-pain agent (e.g. amitriptyline): "There's a tablet that helps nerve pain? Are there side effects I should know about?" (The tested point is initiating a first-line neuropathic agent with appropriate counselling.)
- ●If the Doctor emphasises foot protection/podiatry: "So because I've lost feeling, my feet are more at risk? What do I need to do to protect them?" (The tested point is foot-risk assessment and protection given loss of protective sensation.)
- ●If the Doctor arranges a foot examination: "You want to see my feet properly in person? That makes sense."
- ●If the Doctor discusses diabetes/cardiovascular optimisation: "Is there anything else I should be doing with my diabetes or medication?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
0 / 16 indicators checked+0−0
Positive (0/8)
Negative (0/8)
Domain 2: Clinical Management and Medical Complexity
0 / 18 indicators checked+0−0
Positive (0/9)
Negative (0/9)
Domain 3: Relating to Others
0 / 12 indicators checked+0−0
Positive (0/6)
Negative (0/6)
Clinical Learning Points
1
Diabetic Peripheral Neuropathy
- ●Diabetic peripheral (sensory) neuropathy typically causes bilateral, symmetrical, 'stocking'-distribution burning/tingling/numbness, often worse at night. It reflects nerve damage from diabetes and is a major risk factor for foot ulceration.
- ●Existing nerve damage is generally not reversible; the aims are symptom control and preventing complications.
2
Loss of Protective Sensation and Foot Risk
- ●Reduced monofilament sensation = loss of protective sensation, markedly increasing the risk of unnoticed injury, ulceration, and amputation. This mandates foot-risk assessment, podiatry, foot-care education, appropriate footwear, and daily foot checks (NICE NG19).
3
Distinguish Neuropathy from Peripheral Arterial Disease
- ●In a diabetic foot, distinguish neuropathy from peripheral arterial disease: claudication (calf pain on walking, relieved by rest), coldness, colour change, and absent pulses point to vascular disease. Both may coexist; assessment includes pulses and, if indicated, ABPI.
4
Neuropathic-Pain Treatment (NICE NG215/CG173)
- ●First-line options for neuropathic pain are amitriptyline, duloxetine, gabapentin, or pregabalin (choose one; switch if ineffective/not tolerated). Amitriptyline at night suits night-predominant symptoms.
- ●Counsel on side effects, titration, delayed benefit, and that response varies.
5
Exclude Other Causes
- ●Confirm B12 is normal and consider alcohol and other contributors — do not assume diabetes is the sole cause of a neuropathy.
6
Optimise Glycaemia and Cardiovascular Risk
- ●Reinforce good glycaemic control (which slows progression), and manage cardiovascular risk — statin, blood pressure, and consideration of an SGLT2 inhibitor for cardiovascular/renal benefit where indicated.
7
Foot-Care Education and Safety-Netting
- ●Educate on daily foot inspection, careful skin/nail care, checking footwear, and seeking prompt help for any wound — and safety-net clearly, given the loss of protective sensation.
8
Common Candidate Mistakes in This Case
- ●Not protecting the feet: treating the pain but overlooking foot-risk assessment/podiatry despite loss of protective sensation.
- ●Not examining the feet: managing remotely without arranging in-person foot examination.
- ●Failing to distinguish neuropathy from vascular disease: not screening for claudication/pulses.
- ●Poor neuropathic-pain management: no first-line agent, or no counselling/review plan.
- ●Neglecting glycaemic/cardiovascular optimisation: focusing only on the pain.
Free MRCGP SCA practice case for GP registrars covering Burning Feet At Night and Numbness On His Last Foot Check — Metabolic Problems and Endocrinology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.
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