You are an FY2 in GP

Personal Details:

Name: Priya Sharma

Age: 30

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

Priya attended a week ago, complaining of persistent tiredness. She has been a vegetarian for two years for religious reasons. Blood tests were performed.

Investigation Results:

Hb: 10.1 g/dL (Low)

MCV: 108 fL (High)

Ferritin: 30 ng/mL (Normal)

Iron: 13 µg/dL (Normal)

Folic acid: 12 nmol/L (Normal)

Vitamin B12: 100 pg/mL (Low)

Task:

1. Explain the blood test results

2. Address her concerns

3. Discuss the management plan.

Opening Sentence: “Hi, Doctor, you asked me to come in to talk about my blood test results.”

Open History (to give freely): “I’m still feeling so tired all the time. It’s really hard to keep up with my job and look after the kids. I just have no energy.”

Cues to give: “I really don’t want to change my diet; my religion is very important to me.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I thought being vegetarian was supposed to be healthy. I don’t understand why I’m so tired.”

Concerns: “Is there something seriously wrong with me? Will I have to start eating meat again?”

Expectation: “I hope you can give me something to make me feel less tired.”

How to Act: You are visibly fatigued and frustrated. You are firm but polite about your religious and dietary beliefs.

More History (only if asked): You became a vegetarian two years ago. You do not eat any meat, fish, or eggs. You do consume dairy products like milk and cheese. Your periods are regular, and your mood is generally fine, just exhausted. You haven’t had any numbness or tingling, or weakness in your arms or legs. You have no other medical problems.

Social History: You work as an accountant and have two young children. Your tiredness is significantly affecting your ability to work and care for them.

Questions to ask:

What is Vitamin B12? Why is mine low?

Do I have to have injections? I hate needles.

Will I have to take this treatment forever?

Opening & Reviewing Symptoms:

Hi Priya, thanks for coming in. We have your blood results, which I’ll explain in a moment. First, how have you been feeling since I last saw you? Is the tiredness still the main issue?

Dietary History: Last time you mentioned you follow a vegetarian diet for religious reasons. Can you tell me a bit more about that? What kinds of foods do you typically eat? Do you eat any animal products at all, like milk, cheese, or eggs?

Exploring Other Causes/Symptoms: Apart from tiredness, have you noticed any other symptoms, like pins and needles in your hands or feet, a sore tongue, or any problems with your memory?

How are your periods? Are they particularly heavy?

ICE (Ideas, Concerns, Expectations): What were your own thoughts about why you might be feeling so tired?

What was your biggest concern? Were you worried you might have to change your diet?

What were you hoping for from the blood tests?

Explain the new results:

Thanks for coming in, Priya. We have your blood results, and they have given us a clear reason for why you’ve been feeling so tired. The tests show that you have a type of anaemia, which means you have a lower number of red blood cells than normal. Specifically, it’s caused by a lack of Vitamin B12.

Addressing and answering the patient’s ICE:

You’re worried about what this means and if you’ll have to change your diet. Let me reassure you, we can absolutely respect your religious beliefs. Vitamin B12 is a nutrient that is mainly found in animal products like meat, fish, and eggs. Because you have cut these out of your diet, your body’s stores of this vitamin have slowly run out, leading to anaemia. We don’t need you to start eating meat; we can replace the vitamin in another way.

Next Steps:

To get your energy levels back to normal, we need to replace the missing Vitamin B12. Because your level is very low and you have symptoms, the quickest and most effective way to do this is with a course of injections. This involves an injection every other day for two weeks to build your levels back up quickly. I know you don’t like needles, but the nurses are very gentle, and this initial course will make you feel better much faster than tablets would.

Self-help measures:

After the initial course of injections, we will need to continue with maintenance treatment to stop the problem from coming back. This would typically be one injection every 2-3 months. This will likely be a lifelong treatment as long as you continue with your current diet. The other option is to give you an oral vitamin B12 tablet that you take on a regular daily basis.

We can also discuss dietary sources of B12 that are suitable for vegetarians, such as fortified breakfast cereals and yeast extract, but these are often not enough on their own once a deficiency has developed.

We should re-check your blood count in a few months to make sure the treatment is working effectively. You should start to feel a significant improvement in your energy levels within a couple of weeks of starting the injections.

Addressing ideas, concerns, and expectations: Clearly explain the link between her diet and the specific type of anaemia. Reassure her that her dietary beliefs can be respected. Manage her expectation for a simple pill by explaining why injections are the recommended first-line treatment.

Explain the need for a loading course of intramuscular hydroxocobalamin (Vitamin B12). Explain the schedule for the loading dose and the plan for long-term maintenance therapy. Arrange for her to book in with the practice nurse.

What is scenario testing? This case tests the candidate’s ability to interpret blood results, explain a specific diagnosis, and create a management plan that respects a patient’s cultural and religious beliefs. It requires sensitive communication to negotiate a treatment plan (injections) that the patient may be hesitant about.