Station 60
Olusegun Arinze
Age: 56 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Begin by acknowledging the reason for today’s consultation and referring to the previous appointment:
“Olusegun, I see you’re here to discuss your blood test results. Is it okay if I ask a few questions to help explain the results better? From the notes, I see you saw my colleague about tiredness and joint aches, and some blood tests were arranged. How have your symptoms been since then—have they improved or worsened?”
This approach demonstrates that you are making appropriate use of the information provided and are engaging with the patient’s journey. Failure to do so may be marked negatively by the examiner.
- Ask specifically about bone pain (e.g. in skull, pelvis, spine or long bones), as this may suggest Paget’s disease
- Ask about red flag symptoms such as weight loss and night sweats
- Ask whether the patient has had any previous fractures or falls
- Ask about sunlight exposure, particularly during winter months
- Ask about jaundice, abdominal pain, dark urine, or pale stools (to screen for liver causes of raised ALP)
- Ask how long the patient has been on statin therapy, and whether any side effects have previously been noticed
- Explore social history, including smoking and alcohol intake, and ask about dietary habits, especially calcium and vitamin D intake
- Ask about the patient’s occupation, and explore how the symptoms of fatigue and joint pain have impacted their daily functioning and quality of life
Example of explanation to patient
Olusegun, thanks for coming back to go over your blood results. I can see you’ve been feeling quite tired and have had some general joint aches. The good news is that most of your blood tests, including your thyroid, blood sugar, inflammation markers, and liver function to an extent, are all within normal limits.
However, two results stood out. Firstly, your vitamin D level is very low. Vitamin D plays an important role in bone and muscle health, and when it’s low, it can lead to symptoms like tiredness and joint aches, exactly what you’ve been experiencing.
Secondly, one of your liver and bone markers, called ALP, is slightly raised. This can sometimes happen when vitamin D levels are low, so it’s very possible that these findings are linked and helping to explain how you’ve been feeling.
We’ll start you on a course of vitamin D tablets to bring your levels back up. You asked whether you’ll need to take vitamin D long term, and that’s a really good question. For many people, once their levels improve, they don’t need ongoing treatment. In your case, because you don’t get much sun exposure and people with darker skin naturally produce less vitamin D from sunlight, we may recommend a small maintenance dose for longer. But we’ll keep an eye on your levels with follow-up tests and adjust things as needed.
Other ways to improve your vitamin D levels include, eating more vitamin D-rich foods like oily fish, eggs, and fortified cereals, and getting some sunlight when you can. I’ll send you a short questionnaire about your diet to check your calcium intake, as this works hand-in-hand with vitamin D for bone health.
One more thing to mention is your smoking. I know it’s been a part of your life for a long time, but it does increase your risk of heart disease and stroke, especially with your existing blood pressure and cholesterol. If you’ve ever thought about cutting down or quitting, I’d be really happy to help and can refer you to free local services that support people through it. What are your thoughts on that today?
Finally, if you notice your symptoms getting worse or you develop anything new, like severe pain, weakness, or changes in your general health, please get in touch with us sooner. Otherwise, we’ll check in again after your treatment to see how you’re doing and repeat those tests
Management
Management
- Offer to start vitamin D supplementation using a suitable loading dose regimen: for example, 800 IU five times daily for 10 weeks (total 280,000 IU), or 50,000 IU once weekly for 6 weeks (total 300,000 IU)
- After completing the loading regimen, start on a maintenance dose of 800 IU daily
- Advise that blood tests will be repeated in 6 to 10 weeks, depending on the chosen loading regimen, to monitor calcium, vitamin D levels, and ALP
- Assess dietary calcium intake using the calcium calculator; advise that this will include questions about foods like milk, cheese, and yoghurt to estimate daily intake
- Provide lifestyle advice to improve diet and increase safe sun exposure; recommend incorporating vitamin D-rich foods such as oily fish, eggs, and fortified cereals
- Explain that lifelong supplementation is not always necessary; with improved diet and sun exposure, many people maintain adequate vitamin D levels. However, due to his risk factors (darker skin, limited sun exposure), long-term low-dose supplementation may be needed, and future decisions will be guided by blood tests
- Offer smoking cessation support in a non-judgemental manner and if he’s open to it, offer self-referral to local smoking cessation services.
- Safety net: Advise him to contact the surgery urgently if his symptoms worsen or do not improve, or if he develops any new concerning symptoms.
Learning point from this station:
Statins can sometimes cause muscle aches, but in this case, it seems less likely. The patient has been taking the medication for several years without problems, and his blood tests show a low vitamin D level, which is a more likely cause of his symptoms. If the statin were affecting his liver, we would usually see changes in other liver blood tests, which we don’t see here. Stopping the statin now, while also starting treatment for vitamin D deficiency, would make it harder to know what actually helped when we review him in a few weeks. It could also mean taking away the heart protection that statins give, which may not be necessary.
Another possible cause of a raised ALP is Paget’s disease of bone, which can sometimes present with an isolated elevation in ALP. However, this is less likely here because the patient is not experiencing typical symptoms such as localised bone pain (especially in the skull, spine, or pelvis) and there is an obvious vitamin D deficiency which can explain raised ALP.
Therefore, starting vitamin D treatment and repeating the blood test to check for improvement in ALP is a reasonable first step. If ALP levels remain elevated despite adequate vitamin D replacement, then Paget’s disease can be considered and investigated further at that point