PUID: 42 || Vitamin D Deficiency in PLAB 2: Diagnosis, Safety Netting, and Effective Consultation, a PLAB 2 Mock- Attempt 2

Practice a case with the AI patient 🤖

Summary:

A female patient presents with tiredness and constipation. Blood tests reveal vitamin D deficiency with mild hypocalcemia. The scenario tests your ability to explain results, manage nutritional deficiencies, provide safety netting, and maintain patient-centred communication under time constraints.

Key Points:

Presenting Complaint & Prioritisation

• Patient presented with tiredness (main impact on life) and constipation

• Focus the consultation on tiredness as primary complaint, while addressing constipation appropriately

Data Gathering

• Confirm onset, duration, variation during the day

  • Morning tiredness: rheumatoid arthritis or autoimmune causes

  • Evening tiredness: myasthenia gravis or osteoarthritis

• Check:

  • Sleep patterns and quality

  • Mood changes

  • Bone pain or back pain (vitamin D deficiency signs)

  • Muscle cramping or weakness

  • Associated symptoms: weight loss, bowel changes (malignancy red flags)

• Review:

  • Medical history

  • Family history

  • Lifestyle factors affecting vitamin D (diet, sun exposure)

Clinical Findings & Interpretation

• Blood tests:

  • Vitamin D deficiency identified as cause of hypocalcemia and tiredness

  • Thyroid function and hemoglobin normal

• Explain:

  • Avoid jargon (e.g. “hemoglobin” without context)

  • Use lay terms: “Your blood count is normal, meaning you are not anaemic.”

Management

• Vitamin D supplementation

  • Loading dose for deficiency correction (e.g. high dose cholecalciferol for weeks)

  • Maintenance dose for prevention

• Calcium supplementation if required based on deficiency extent

• Dietary advice:

  • Increase intake of oily fish, eggs, fortified foods

  • Increase safe sun exposure

• Lifestyle advice:

  • Exercise for bone strength and fatigue improvement

• Referral:

  • Gastroenterology referral if concerned about malabsorption due to constipation or if symptoms persist despite correction

• Follow-up plan:

  • Reassess blood levels in 6 months

• Safety netting:

  • Advise patient to return if experiencing:

    • Weight loss

    • Worsening fatigue

    • New bowel changes

Communication Skills

• Explain blood results clearly:

  • What was tested

  • Why it was tested

  • What was found (normal vs abnormal)

• Always link management to the presenting complaint:

  • “We’re giving you vitamin D because that is likely the cause of your tiredness.”

• Avoid overcomplicating explanations when time is limited

• Summarise management plan in one breath before expanding:

  • Supplements → Diet/lifestyle → Referral → Safety netting → Follow-up → Leaflets

• Use natural empathy, avoid stock phrases that sound rehearsed

Ethical Considerations

• Ensure patient understanding and consent for treatments

• Respect patient autonomy in decision making

• Provide clear safety netting to avoid medico-legal complaints, aligning with GMC Good Medical Practice guidelines

Diagnostic Approach

1. Take a focused history of tiredness and constipation

2. Rule out serious causes: malignancy, endocrine disorders

3. Review blood tests for:

   • Vitamin D deficiency

   • Hypocalcemia

   • Thyroid function

   • Hemoglobin levels

4. Link symptoms with biochemical findings to form a diagnosis

Management

1. Explain results in lay language

2. Prescribe appropriate loading and maintenance doses of vitamin D

3. Offer dietary and lifestyle advice

4. Consider calcium supplementation if hypocalcemia is clinically significant

5. Refer to gastroenterology if constipation persists or malabsorption suspected

6. Safety net for red flag symptoms (weight loss, worsening fatigue)

7. Arrange follow-up in 6 months

8. Provide leaflets for patient education

Important Considerations

• Always treat the presenting complaint during consultation

• Link findings to management clearly for patient reassurance

• Include safety netting as standard practice

• Avoid medical jargon without explanation

• Manage time efficiently – summarise management when short on time

Communication Skills

• Use empathetic, natural language

• Avoid excessive reassurance if it consumes time

• Summarise and prioritise management plans efficiently

• Engage the patient with questions like:

  • “Which part of the management would you like to discuss in detail?”

Additional Resources

• NICE Guidelines on Vitamin D deficiency in adults

• GMC Good Medical Practice (2024 update)

• PLAB 2 Examiner Top Tips