History Taking · Intermediate · Endocrinology

Fatigue and Bone Pain in a 68-Year-Old Man

Practise this PLAB 2 history taking station on Primary Hyperparathyroidism. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Peter Gao, a 68-year-old man, has come to see you with complaints of persistent fatigue, bone pain, and difficulty concentrating. He has also noticed increased thirst and polyuria. Blood tests from two months ago showed elevated calcium. Please take a focused history and discuss your initial management plan with the patient.

Background notes: PMH: Hypertension, Type 2 DM, Previous MI age 53 (angioplasty/stent), Osteoarthritis knees/lower back, Fall 2 yrs ago with Fx left wrist

What this station tests

  • Connecting 'bones, stones, abdominal groans, psychic moans' to hypercalcaemia: recognising the symptom constellation
  • Identifying the missed elevated calcium as a clinical gap: addressing it without blaming colleagues
  • PTH as the key diagnostic investigation: high calcium plus high PTH confirms primary hyperparathyroidism
  • Addressing the dementia fear: cognitive symptoms from hypercalcaemia are reversible with treatment
  • Recognising the wrist fracture as potentially pathological: bone resorption from hyperparathyroidism weakens bone

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

The classic teaching mnemonic for hypercalcaemia is 'bones, stones, abdominal groans, and psychic moans.' Candidates must connect seemingly unrelated symptoms (bone pain, fatigue, confusion, polyuria) through the elevated calcium result. Mr Gao is 68, presenting with months of fatigue, bone pain, and difficulty concentrating. Blood tests from 2 months ago showed elevated calcium but no follow-up was arranged. Open with: 'Mr Gao, I can see you have been feeling unwell for some time and there are some blood results we need to discuss. Tell me how you have been.'

Core approach

Connect his symptoms to hypercalcaemia. Fatigue and cognitive slowing ('psychic moans'): exhausted, cannot concentrate on reading or crosswords, daughter has noticed episodes of confusion. Bone pain ('bones'): generalised aching, particularly back and legs. He had a wrist fracture 2 years ago from a minor fall (possible pathological fracture from bone resorption). Increased thirst and polyuria ('stones' and renal effects): drinking more, urinating frequently. Constipation ('abdominal groans'). Reduced appetite. Low mood. These are all features of hypercalcaemia.

His elevated calcium from 2 months ago was not acted upon. Address this gap without blaming colleagues: 'I can see the blood test showed elevated calcium. I want to investigate this properly today to understand what is causing it and your symptoms.'

The most likely cause at his age is primary hyperparathyroidism (PTH-mediated hypercalcaemia). Exclude other causes through history: no malignancy symptoms (no weight loss, no new lumps), not on lithium or thiazides (which can elevate calcium), no excessive calcium or vitamin D supplementation. His previous MI and diabetes are relevant for surgical fitness assessment.

ICE: He worries about dementia (cognitive symptoms), cancer (bone pain and fatigue), and his previous calcium result being ignored.

Closing and safety netting

Explain the likely diagnosis: 'Mr Gao, the elevated calcium in your blood is very likely causing most of your symptoms: the tiredness, the bone aches, the difficulty concentrating, and the increased thirst. The most common cause at your age is an overactive parathyroid gland, which regulates calcium.' Address his dementia fear: 'The confusion you have been experiencing is more likely caused by the high calcium than by dementia. If we treat the calcium, this should improve.'

Investigations: repeat calcium with PTH (the diagnostic combination: high calcium plus high PTH confirms primary hyperparathyroidism), phosphate, vitamin D, renal function, bone profile. DEXA scan for bone density. Renal imaging (ultrasound) for kidney stones.

Treatment: if primary hyperparathyroidism is confirmed and he meets surgical criteria (symptomatic, calcium significantly elevated, osteoporosis, or renal impairment), parathyroidectomy is curative. Safety net: 'If you become very confused, develop severe nausea and vomiting, or have significant abdominal pain, go to A&E as very high calcium can be dangerous.' Urgent endocrinology referral.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for primary hyperparathyroidism. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Symptom cluster connected to hypercalcaemia. Previous fracture identified as potentially pathological. Causes of hypercalcaemia screened (medications, supplements, malignancy). Missed calcium result addressed.

Costs marks: Not connecting symptoms to calcium. Missing the fracture significance. Not screening for causes.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Calcium with PTH as diagnostic investigation. DEXA and renal USS planned. Endocrinology referral. Parathyroidectomy as curative option explained. Severe hypercalcaemia safety netting.

Costs marks: Not measuring PTH alongside calcium. No bone density assessment. No referral. No safety netting for severe hypercalcaemia.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Addressing dementia fear with reversibility reassurance. Explaining the missed calcium result without blame. Providing hope that treatment should improve symptoms. Involving his daughter.

Costs marks: Not addressing dementia fear. Being critical of colleagues. Not providing hope about treatment.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not connecting the disparate symptoms through the calcium result. Bone pain, fatigue, confusion, polyuria, and constipation are often investigated separately. The elevated calcium result is the unifying diagnosis. Candidates who take the symptoms in isolation miss the pattern.
  2. Not addressing the cognitive symptoms as potentially reversible. Mr Gao is terrified of dementia. Candidates who do not explicitly reassure him that hypercalcaemic confusion is treatable and reversible leave him with his greatest fear unaddressed.
  3. Not recognising the missed calcium result as a patient safety issue. The elevated calcium was identified 2 months ago with no follow-up. Candidates should acknowledge this gap and ensure it does not happen again.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this primary hyperparathyroidism station?

The classic teaching mnemonic for hypercalcaemia is 'bones, stones, abdominal groans, and psychic moans.' Candidates must connect seemingly unrelated symptoms (bone pain, fatigue, confusion, polyuria) through the elevated calcium result. Mr Gao is 68, presenting with months of fatigue, bone pain, and difficulty concentrating. Blood tests from 2 months ago showed elevated calcium but no follow-up was arranged.

What does a strong performance look like to the examiner in this station?

Strong performances show: Symptom cluster connected to hypercalcaemia. Previous fracture identified as potentially pathological. Causes of hypercalcaemia screened (medications, supplements, malignancy). Weak performances: Not connecting symptoms to calcium. Missing the fracture significance. Not screening for causes.

What is the biggest pitfall in this primary hyperparathyroidism station?

Not connecting the disparate symptoms through the calcium result. Bone pain, fatigue, confusion, polyuria, and constipation are often investigated separately. The elevated calcium result is the unifying diagnosis.

How should I prepare for primary hyperparathyroidism if I have never seen it in practice?

Structure beats experience here. Focus on identifying the missed elevated calcium as a clinical gap: addressing it without blaming colleagues. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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