CCE-CBD-065

Examiner Only Information

Questions

Q1. How would you explain David’s diagnosis and its underlying cause?

• Prompt: How do you explain vitamin D deficiency in simple terms?
• Prompt: What are the key causes in his case?

Q2. What further investigations would you consider and why?

• Prompt: When would you check bone density (DEXA scan)?
• Prompt: What blood tests are useful for secondary causes?

Q3. How would you manage David’s vitamin D deficiency?

• Prompt: What dose and duration of vitamin D supplementation would you prescribe?
• Prompt: How would you monitor response?

Q4. What lifestyle modifications would you recommend to improve his vitamin D status?

• Prompt: How much sun exposure is recommended for adequate vitamin D?
• Prompt: What dietary changes should he make?

Q5. When would you refer David for specialist assessment?

• Prompt: When is an endocrinology referral needed?
• Prompt: When would osteoporosis management require a specialist?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you explain David’s diagnosis and its underlying cause?

The competent candidate should:

• Explain vitamin D deficiency in simple terms:
  • “Vitamin D is essential for strong bones, muscle function, and immune health. It helps the body absorb calcium, which keeps bones healthy.”
  • “Your vitamin D level is quite low, which may be contributing to your fatigue and muscle aches.”
• Identify key contributing factors in this case:
  • Minimal sun exposure (indoor work, sun avoidance).
  • Low dietary intake (minimal dairy and fatty fish).
  • Overweight (vitamin D stored in fat, reducing bioavailability).
• Reassure and discuss the next steps:
  • “This is common, especially in people who spend little time outdoors. Fortunately, we can correct it with supplementation and lifestyle changes.”

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Q2: What further investigations would you consider and why?

The competent candidate should:

• Consider additional blood tests if warranted:
  • Calcium, phosphate, parathyroid hormone (PTH) to assess secondary hyperparathyroidism.
  • Alkaline phosphatase (ALP) as a marker of increased bone turnover.
• Assess bone health risk:
  • DEXA scan (bone density test) indicated due to his age and family history of osteoporosis.
  • “Since your mother had osteoporosis, it’s important to assess your bone health to prevent fractures in the future.”

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Q3: How would you manage David’s vitamin D deficiency?

The competent candidate should:

• Prescribe appropriate vitamin D supplementation:
  • Cholecalciferol 1,000–2,000 IU daily for maintenance OR 3,000–5,000 IU daily for 6–12 weeks if moderate to severe deficiency.
• Provide follow-up plan:
  • Recheck vitamin D levels in 3 months.
  • Assess calcium and bone markers if deficiency is persistent.

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Q4: What lifestyle modifications would you recommend to improve his vitamin D status?

The competent candidate should:

• Safe sun exposure guidelines:
  • “Aim for 10-15 minutes of sun exposure to the arms and face before 10 am or after 3 pm, most days of the week.”
  • “If you’re concerned about skin cancer, short sun exposure outside peak UV hours is still beneficial.”
• Dietary recommendations:
  • Increase vitamin D-rich foods (fatty fish, egg yolks, fortified dairy, and cereals).
  • “Consider a dietitian referral if further guidance is needed.”
• Encourage weight-bearing exercise:
  • Walking, resistance training, or weightlifting to support bone health.

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Q5: When would you refer David for specialist assessment?

The competent candidate should:

• Endocrinology referral if:
  • Persistent deficiency despite supplementation.
  • Suspected malabsorption (e.g., coeliac disease, chronic liver/kidney disease).
• Osteoporosis specialist referral if:
  • DEXA scan shows significant bone loss.
  • Fracture risk assessment (FRAX) suggests high risk.

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SUMMARY OF A COMPETENT ANSWER

• Clearly explains vitamin D deficiency and its health impact.
• Identifies risk factors and orders appropriate investigations.
• Prescribes evidence-based supplementation with monitoring.
• Provides lifestyle and dietary recommendations.
• Recognises when specialist referral is required.

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PITFALLS

• Failing to recognise vitamin D deficiency risk factors.
• Not considering secondary causes (malabsorption, renal/liver disease).
• Inadequate supplementation dosing or lack of follow-up.
• Neglecting bone health assessment in a high-risk patient.

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REFERENCES

• RACGP Guidelines on Vitamin D and Bone Health
• National Institutes of Health on Endocrinology (Vitamin D Deficiency)
• Australian Dietary Guidelines on Vitamin D Intake

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Clearly explains vitamin D deficiency and its impact.

2. Clinical Information Gathering and Interpretation

2.1 Identifies risk factors for deficiency and bone health concerns.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates simple deficiency from more complex causes.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate supplementation and follow-up plan.

5. Preventive and Population Health

5.2 Advises on sun exposure, diet, and exercise for long-term prevention.

6. Professionalism

6.3 Addresses patient concerns and involves them in decision-making.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate testing and prescribing within Medicare guidelines.

9. Managing Uncertainty

9.1 Recognises when further assessment or endocrinology referral is needed.

10. Identifying and Managing the Patient with Significant Illness

10.3 Detects osteoporosis risk requiring intervention.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD