Cases/Metabolic Problems and Endocrinology

Burning Feet Who Mentions A Blister She Never Felt — Free SCA Practice Case

Woman with burning feet who mentions a blister she never felt

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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

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Materials for Candidate

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Patient Profile

Full Name

Beryl Cattermole

Age

71 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Booked call.

Reason for Encounter

"Burning feet at night. Would like something stronger than paracetamol."

Medical Records

●PMH: Type 2 diabetes for 15 years. Diabetic retinopathy. Osteoarthritis of both knees.
●Medications: Metformin 1 g twice daily, sitagliptin 100 mg once daily, atorvastatin 20 mg, paracetamol 1 g as needed.
●Allergies: NKDA.
●Social: Widow, lives alone. Non smoker.

Recent Notes

●Bloods, 1 month ago: HbA1c 74 mmol/mol, eGFR 58.
●Diabetes reviews: last two not attended.

Patient Script

For the friend playing the patient role

Character Overview: You are Beryl Cattermole, a 71 year old widow who retired from the post office counter in the village where she still lives. You live alone in a bungalow. Your husband Alwyn died three years ago. You have had type 2 diabetes for 15 years and think of it as "a touch of sugar" that tablets look after. It has damaged the back of your eyes, so you cannot read small print or see the soles of your feet properly. Your knees are bad. You are practical, a bit stoic and a bit brusque, and you dislike fuss and being told off. Your voice is tired because you have slept badly for weeks. You want a stronger painkiller for your burning feet so you can sleep. You are quietly terrified of losing your independence, but you say so only if the doctor asks how you feel.

Opening Sentence: "Hello, doctor. It's my feet. They burn at night so badly I can't sleep, and the paracetamol doesn't touch it. I'd like something stronger, please."

History if Asked (Data Gathering Phase)

●The burning: "Both feet, from the toes to about the ankle, a bit worse on the right. It started months ago as tingling, but for the last six weeks it's been proper burning, like they're held near a fire. Sometimes stabbing."
●When it is worst: "Night. Once I'm in bed it gets going, and even the weight of the duvet on my toes is horrible. I get about three hours' sleep. In the day it's duller, more pins and needles."
●Numbness: "That's the odd part. Parts of my feet feel dead as well. In the bath I can't tell how hot it is with my feet. I don't feel the carpet properly."
●Other symptoms: "No weakness. My hands are fine. No back pain, nothing shooting down my legs. Nothing in my bladder or bowels."
●What she has tried: "Paracetamol, two or three times a day. Nothing else."
●Walking and circulation (if asked): "My knees stop me before my legs do. No cramps in my calves. My feet aren't cold as far as I know, and nobody has mentioned a toe going a different colour."
●Falls and balance (if asked): "A couple of near things on the step at the back door. I caught the rail once. I put it down to my eyes and my knees. I've not actually gone down."
●Sugars, thirst and passing water (if asked): "I'm a bit thirsty, I suppose, and up once or twice in the night for the toilet. I don't test my sugars at home. Nobody's ever asked me to."
●Alcohol and weight (if asked): "A sherry at Christmas, that's all. My weight goes up and down but nothing sudden."
●B12, diet and stomach (if asked): "I've never heard of anyone checking that. Ready meals mostly, and toast. No stomach trouble."
●The hidden problem (only if the doctor asks about her feet generally: the skin, sores, blisters, cuts, plasters, anything wrong, or what they look like): "Well, now you say it, there's a blister on the ball of my left foot, under the big toe. I found it about a week ago when my sock stuck to it. It doesn't hurt at all. I put a plaster on it. It's weeping a bit now and it's got a smell, if I'm honest. I changed the plaster this morning."
●More about the blister (if asked): "About the size of a ten pence piece. I can't see it properly. I haven't popped it or cut it. I've been walking about on it as normal, in my slippers. I've put antiseptic cream on twice."
●Fever, redness, feeling unwell (if asked): "No temperature. I haven't been hot or shivery. I can't see redness, but I can't feel anything creeping up my leg. I'm tired, but that's the sleep."
●Why she did not mention the blister (if asked): "Because it doesn't hurt. I've got burning feet, why would I worry about something that doesn't hurt?"

Ideas, Concerns, Expectations

Gating note: Beryl does not volunteer any of the following. Each part comes out only when the doctor asks what she thinks is going on, what worries her, or what she was hoping for.

●Ideas: "I think it's just age and the sugar. Everybody my age gets it. I thought you'd give me something stronger and that would be that."
●Concerns: "I'm worried it's the start of things going downhill. I've seen it with other people. One minute they're at home and the next it's a bed in a home somewhere. I'd rather die in this bungalow. If I can't manage my own feet, I can't manage."
●Expectations: "A proper painkiller so I can sleep. Co codamol, or tramadol like my friend gets. I didn't think I'd be asked about the rest of me."

If Asked: Medical History and Medications

●Diabetes: "Fifteen years. Metformin morning and night and the other tablet in the morning. I've never needed insulin and I don't want it. I couldn't see to do it."
●Eyes: "I go to the eye clinic every so often. They've lasered the back of my eyes. I can't read the print on the boxes, so I know them by shape and the pharmacist labels them in big letters."
●Reviews: "I've missed the last two. I can't read the letters or the texts. When the surgery rings it's often a number I don't know, so I don't answer. I felt fine, so I thought it was only blood tests."
●Last foot check: "Somebody tested my feet with a little thread a year or two back. They said they were a bit numb but nothing to worry about."
●Knees: "Arthritis, both. Paracetamol when it's bad. I was told years ago not to take ibuprofen because of my kidneys, so I don't."
●Other conditions: "A cholesterol tablet at night. No heart trouble, no stroke. No allergies. Never smoked."

Social History and Lifestyle Impact

Note: Beryl gives this naturally as it comes up.

●Home: A bungalow she and Alwyn bought forty years ago. She does her own washing, cooking and bins, and has a cat called Pudding.
●Help: Her daughter Hayley lives two hours away and rings on Sundays. Her neighbour Raymond does her shopping, puts the bins out and drives her to appointments, since she gave up driving when her eyes went. She does not like asking him for too much.
●Daily life: A coffee morning at the village hall on Thursdays. The back step is steep. She wears slippers all day because shoes feel tight and the burning is worse in them.
●Impact: "I'm shattered. I nod off in the chair before lunch. I'm not doing my garden. If I'm honest I'm getting low with it, and I wonder whether I can keep going on my own."
●Mood (if asked): Low from tiredness, not hopeless, no thoughts of harming herself, eating normally.

If Asked: Associated Symptoms

●Chest pain, breathlessness or palpitations: None.
●Dizziness on standing: "A little if I jump up too fast. Nothing that's put me on the floor."
●Bowels and bladder: "Regular."
●Vision: "No worse than usual."
●Strokes or fits: None.

Responses to Management (The Negotiation Phase)

●
If the doctor says the foot needs to be seen soon and the foot clinic will be told:
- ●Reaction: Taken aback. "But it doesn't hurt. It's just a blister. Is it as serious as all that?" If told it matters because she cannot feel it: "Oh. I never thought of it like that." She asks how she would get there. Raymond could drive her, though she hates to ask. If a visit or a next day appointment is offered: "Tomorrow would be fine." She may ask quietly, "Could I lose the foot?" and accepts an honest, calm answer.
●
If the doctor asks her to keep weight off it, stop the plaster and cream, or avoid walking about in slippers:
- ●Reaction: Practical. "How am I to do that? I've got the cat to feed and the bins on Tuesday. I can't sit all day." She asks what she should put on it instead, and who can look at it each day since she cannot see it.
●
If the doctor suggests a nerve pain tablet (amitriptyline, duloxetine, gabapentin or pregabalin), or says it is not an ordinary painkiller:
- ●Reaction: Doubtful, then interested. "A nerve tablet? Will it work like paracetamol or take a while? I'm not having anything that makes me dizzy. I'm worried enough about the back step." She asks about side effects, how long she would take it, and why not co codamol or tramadol. If told those work poorly for this pain, she accepts. If amitriptyline is suggested: "Isn't that an antidepressant? Will it muddle me?"
●
If the doctor talks about her sugar, the HbA1c of 74, or changing her diabetes tablets:
- ●Reaction: "I feel all right, so why does it matter?" Once told it helps nerves and healing: "Right, I'll do what I'm told if it helps." She asks, "Not insulin? I can't see to do it." She is relieved if insulin is not planned. About missed reviews she is defensive, then honest: "I couldn't read the letters. I didn't like to say."
●
If the doctor suggests blood tests, including B12, and a diabetes review:
- ●Reaction: "More bloods, fine. But I can't read the letters. Can someone ring me? Could it be at the same visit as the foot appointment?"
●
If the doctor gives vague safety netting, or safety netting that depends on her seeing the foot:
- ●Reaction: "How will I know? I can't see my foot properly. What would I notice?" She is reassured by things she can sense, such as feeling shivery or unwell, a stronger smell or more discharge, or a sudden new pain, and by Raymond or Hayley looking at the foot. She asks whether she should ring the same day or wait for the surgery.

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 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●A 71 year old woman with long standing type 2 diabetes asks for a stronger painkiller for burning feet. The hidden problem is a painless, weeping, smelling blister under the left big toe that she found a week ago and has covered with a plaster. She cannot feel it and cannot see her soles.
●The station tests whether the candidate looks beyond the request. The model plan has four parts: recognise an active diabetic foot problem and get the foot examined and referred to the multidisciplinary foot service within one working day; give interim foot protection advice; treat the painful neuropathy with a drug suited to her; and improve glucose control, with B12 and kidney checks and a diabetes review she can actually attend.
●Alternatives that also pass: seeing her in person the same day or next working day in surgery, at home or through the foot service; any one of the four first line neuropathic drugs if the choice is reasoned; any guideline supported intensification route, now or at an early review once the foot is dealt with.

Recognising an Active Diabetic Foot Problem

●NICE NG19 defines an active diabetic foot problem as ulceration, infection, chronic limb threatening ischaemia, gangrene, or a suspected acute Charcot foot. A weeping blister on a numb foot is an ulcer until proved otherwise, and the smell makes infection likely.
●NG19 says to refer immediately to acute services if the problem is limb or life threatening, such as ulceration with fever or any sign of sepsis, limb ischaemia, or concern about a deep soft tissue or bone infection. For all other active foot problems, refer within 1 working day to the multidisciplinary foot care service or foot protection service, for triage within a further working day.
●On a telephone call the candidate cannot judge depth, infection or perfusion, so the foot has to be examined in person promptly; because suspected infection should be treated as soon as possible, seeing her today is ideal where it can be arranged. A home visit, a same day or next day appointment, or a call to the foot service who then see her all meet that need.
●Pain is not a guide. Neuropathy removes the warning, so a painless wound is not a reassuring one.

Assessing for Infection and Ischaemia

●Ask about fever, rigors, feeling unwell, spreading redness, increasing discharge or smell, calf pain on walking, cold feet and any toe changing colour. Beryl has none of the severe features, which is why a next working day route is acceptable. Any of them would shift the plan to same day hospital assessment.
●NG19 advises that when infection is suspected and a wound is present, a sample or deep swab is taken before antibiotics, and that antibiotics are started as soon as possible for suspected infection, chosen according to severity. The decision can be made at the in person assessment. Starting antibiotics by telephone without seeing the foot is not required.

Interim Foot Protection

●Keep weight off the foot as far as possible, avoid walking barefoot or in thin slippers, and stop adhesive plasters and antiseptic creams. Keep the area clean and covered until seen.
●Offloading must be made practical for a woman who lives alone with a cat and a back step. A neighbour, her daughter or a district nurse can look at the foot each day because she cannot.
●Do not promise an outcome. If she asks whether she could lose the foot, answer honestly: early expert care gives the best chance of healing, and the foot team will explain the position after they have seen it.

Painful Diabetic Neuropathy: Choosing a Drug

●NICE CG173 says to offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain, to try another of the four if the first fails or is not tolerated, and not to start drugs such as topiramate or long term tramadol in non specialist settings. Paracetamol, codeine combinations and anti inflammatory painkillers do not treat neuropathic pain.
●All four are valid, so the reasoning matters. Amitriptyline carries anticholinergic effects, drowsiness and postural hypotension, which matter in an older woman with near falls. Duloxetine is licensed for diabetic neuropathic pain and has few anticholinergic effects, but can cause nausea, dizziness and low sodium in older people, and is avoided when creatinine clearance is below 30 mL a minute. Gabapentin and pregabalin need dose adjustment for renal function and can cause drowsiness and dizziness. With an eGFR of 58, a reasoned choice of duloxetine, or a low dose of a gabapentinoid, is easy to defend, while amitriptyline at a low dose is also acceptable if the risks are discussed.
●Start low, increase gradually and review early for benefit, side effects and falls. Benefit can take days to weeks and may be partial. Taper when stopping or switching.
●Capsaicin cream is for localised pain, and is not suitable over a wound. Tramadol is considered only for short term rescue.

Glucose Control

●HbA1c is 74 on metformin and sitagliptin. NICE NG28 (updated 2026) says to agree an individual target. When HbA1c reaches 58 mmol/mol or more on initial treatment, reinforce lifestyle advice and adherence, aim for 53 mmol/mol and intensify; the target can be relaxed for older or frailer people, especially those at risk of falls or of harm from a hypo. Check adherence first: she identifies her tablets by shape.
●For adults who need further medicines and already take a DPP 4 inhibitor, NG28 offers a sulfonylurea, pioglitazone or an insulin based treatment, and for people with frailty it warns that sulfonylureas and insulin raise the risk of hypoglycaemia and falls. Pioglitazone carries fluid retention and fracture risks. She lives alone, has poor sight and has had near falls, so each option has a downside to weigh with her. The 2026 update makes an SGLT 2 inhibitor standard alongside metformin when eGFR is 30 or more, so adding one later is also defensible, but the MHRA advises caution with SGLT 2 inhibitors when foot ulcers or infection are present, so most would defer it until the foot has healed. Whichever is chosen, explain it, agree it, and set a date to recheck HbA1c.
●The agent chosen can be started now or at an early review once the foot is under care. A sensible candidate explains that high sugars impair nerves and healing, but does not rush a risky drug onto a frail woman during a phone call.
●Check kidney function first because drug choice and doses depend on it.

B12, Kidneys and the Overdue Review

●Long term metformin can reduce vitamin B12. The MHRA advises checking B12 when deficiency is suspected, such as with neuropathy, and considering periodic monitoring in those at risk. A low level is treated and metformin is continued as long as tolerated.
●Repeat renal function, since eGFR decides drug doses. Rebook the diabetes review, retinal screening and foot surveillance.
●Her missed reviews have a cause: she cannot read letters or texts and does not answer unknown numbers. The fix is a phone call at an agreed time, large print or a named contact, not another letter.

Safety Netting

●She cannot see her feet, so advice must use what she can sense or someone else can see: fever or shivering, feeling unwell, a stronger smell or more discharge, redness spreading up the leg, a toe turning dark or blue, or sudden severe pain. These mean same day help, by the surgery or urgent care, or 999 if she is very unwell.
●Name who will look at the foot each day, and confirm how she will reach help out of hours.

Relating to Beryl

●Her request is reasonable, so acknowledge it before widening the agenda. Her fear is of losing her independence, which only emerges if asked. Early treatment is the way to protect it, and the honest message is that the aim is to keep her walking and at home.
●Avoid blame about the plaster, the cream or the missed reviews. Use plain words such as a numb foot can be hurt without knowing.
●Check understanding with a teach back, since she cannot read a leaflet, and offer to share the plan with her neighbour or daughter.

Common Mistakes in This Station

●Prescribing co codamol or tramadol as asked and never asking about her feet.
●Asking about feet but treating the blister by telephone, or offering a routine appointment next week.
●Telling her to keep the plaster on and apply cream.
●Choosing a drug without thinking about falls or kidney function, or offering topiramate.
●Ignoring the HbA1c and missed reviews, or not checking B12.
●Vague safety netting that depends on seeing the foot.
●Lecturing her about missed reviews, or promising the foot will be fine.

Mapped to the RCGP curriculum topic: Metabolic Problems and Endocrinology.

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