You are an FY2 in a GP surgery
Personal Details:
Name: Ms Davies
Age: 40
Medical Record:
Past medical history: Fit and well.
Notes:
A 40-year-old woman presents with pain in the ball of her foot.
Task:
1. Take a focused history and examine her foot.
2. Discuss the likely diagnosis and management
Opening Sentence: “Doctor, I’ve got this awful pain in the front of my foot. It’s a sharp, burning pain right here.” (Points to the ball of her foot).
Open History (to give freely): “It’s been getting worse over the last few months. It’s worst when I’m walking, especially when I’m wearing my heels for work. It feels like I’m walking on a pebble. When I get home and take my shoes off, it feels a bit better.
Cues to give: “I love my shoes. I have to look smart for my job.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I don’t know what it is. Maybe I’ve broken a bone?”
Concerns: “Is it serious? Will I need an operation?”
Expectation: “I want something for the pain, but I don’t want to have to give up my heels.”
How to Act: You are a professional woman who is frustrated by the pain but reluctant to change your footwear.
More History (only if asked): The pain is in the right foot only. There was no specific injury. You are otherwise fit and well.
Social History: Works as a secretary.
Questions to ask:
“So it’s all because of my shoes?”
“Are there any exercises I can do?”
Examination: Tenderness over the metatarsal head on the right foot, no other abnormality
History of Presenting Complaint (SOCRATES):
You have pain in the ball of your foot. Can you point to exactly where it hurts?
When did it start? Has it been getting worse?"
What does the pain feel like? You said it was a burning, aching feeling?
What makes it worse? You mentioned standing all day?
What makes it better? Does resting help?
Exploring Risk Factors:
What do you do for a living? This means that you are on your feet a lot. What sort of shoes do you typically wear for work?
Have you had any recent changes in your activity levels?
Red Flag Screening (for stress fracture/nerve issue):
Have you had any injury to your foot?
Have you had any numbness or tingling in your toes?
ICE (Ideas, Concerns, Expectations):
"What were your own thoughts on what might be causing the pain?
What is your biggest worry about this?
What were you hoping we could do to help today?
Explain the likely diagnosis or DD:
Thank you for coming in. That sounds very uncomfortable and is clearly affecting your work.”
(After examination)
I’ve examined your foot, and there are no signs of a fracture or arthritis. The location and type of pain you are describing, especially the feeling of walking on a pebble, is very typical of a condition called metatarsalgia. This is essentially inflammation and pain in the ball of your foot, specifically in the joints where your toes meet the rest of your foot.
Addressing and answering the patient’s ICE:
You’re asking if it’s serious and if you’ll need an operation. No, it’s not a serious condition in that it’s not dangerous, but it is very painful. It is an overuse injury. The main cause is the high-heeled shoes you wear. They force all of your body weight onto that one small area of your foot, which puts immense pressure on the joints and causes inflammation.
Next Steps:
I know you love your shoes and want to look smart, but the most effective treatment is to address the cause. The first and most important step is to switch to wearing comfortable, well-fitted, flat shoes, at least for a few weeks, to allow the inflammation to settle down. I’m not saying you can never wear heels again, but for now, your foot needs a rest.”
Self-help measures:
You can also buy special padded insoles, called metatarsal pads, from a pharmacy. You place them in your shoes, and they act as a shock absorber to take the pressure off the painful area. Simple painkillers like ibuprofen can help in the short term, and applying ice packs can also reduce inflammation. There are also some simple stretching exercises for your calf and Achilles tendon that can help.
If this pain is not improving with these things, I can refer you to a podiatrist, a foot specialist, who can provide custom-made insoles and further advice. But for most people, these simple measures work very well.
The management is conservative and focused on lifestyle changes. 1. Strong advice on footwear modification. 2. Recommend metatarsal pads/insoles. 3. Advise on simple analgesia and ice. 4. Explain the role of a podiatrist as the next step if simple measures fail.
What is scenario testing? This case tests the candidate’s ability to diagnose a common musculoskeletal problem and to provide effective lifestyle and self-care advice. The communication challenge is to negotiate a change in behaviour with a patient who may be resistant to it, by explaining the link between her lifestyle choice (footwear) and her medical problem.