Cases/Learning Disability

Learning Disability Limping — Free SCA Practice Case

Woman with a learning disability limping

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Chloe Davies

Age

32 years

Consultation Type

Video

Age

Accompanying

Susan Davies (Mother and primary carer)

Situation

Video Consultation.

Reason for Encounter

"Chloe is limping and refusing to put weight on her right leg. Brought in by her mother for assessment."

Medical Records

●PMH: Moderate Learning Disability, Epilepsy, Dysmenorrhoea.
●Medications: Sodium Valproate 500mg BD (Epilepsy - under long-term neurology review).
●Depo-Provera (Medroxyprogesterone acetate) 150mg IM every 12 weeks.
●Allergies: NKDA.

Recent Notes

●Last Month: Routine Depo-Provera injection administered by the practice nurse. Noted to have been on this continuously for 12 years to manage heavy, painful periods.

Patient Script

For the friend playing the patient role

Character Overview: You are Susan, Chloe's mother. Chloe (played by the same actor or a secondary role) is sitting next to you, looking uncomfortable and holding her right thigh/hip area. Chloe can answer simple questions ("Does it hurt?" "Yes") but struggles with timelines and complex explanations. You are highly protective of Chloe. She woke up two days ago limping heavily. You didn't see her fall at home. She attends a local adult day centre three times a week. Because there was no obvious accident at home, you have developed a terrifying, hidden suspicion that a staff member or another service user at the day centre might have pushed or hurt her. You will not volunteer this safeguarding fear unless the doctor actively explores your timeline, asks about falls, or asks what you are worried about.

Consultation Flow & Responses:

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The Opening
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If the doctor asks an open question to Chloe: * Chloe: "My leg hurts. It hurts when I walk."
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Susan (Mother): "Hi Doctor. Yes, Chloe has been limping since Tuesday morning. She's really reluctant to put any weight on her right leg, and she winces if she tries to stand up from a chair. I'm really worried."
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Data Gathering (The Layers)
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Layer 1: The Pain & Mechanism (Ruling out severe trauma):
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Susan: "It seems to be her right hip or groin area. I've checked her all over. There's no huge bruise, no swelling that I can see."
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Susan: "She hasn't fallen at home. She's usually very steady on her feet."
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Layer 2: Systemic Screen (Infection vs. Mechanical):
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Susan: "She's eating fine. No fever, she's not hot or sweaty. It's purely the pain when she tries to walk."
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Layer 3: The Medication Trap (Bone Density):
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If asked about her medications: "She takes her Valproate for her seizures, and she's been having the Depo injection for over 10 years because her periods used to cause terrible distress and meltdowns. The nurse just gave her the last one a few weeks ago."
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Layer 4: ICE (The Core Revelation) - ONLY REVEAL IF ASKED:
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If the doctor asks: "What do you think might have caused this?" or "Are you worried about how this happened?"
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Reaction (The Reveal): Susan lowers her voice and looks anxious. "Doctor... I didn't see her fall at home. But she goes to the Willow Day Centre on Mondays. Sometimes it gets rough there with the other service users. I am terrified someone has pushed her, or a staff member has been too forceful. Why else would a healthy 32-year-old suddenly not be able to walk?"

If Asked — Medical History and Medications

●If asked about epilepsy / seizure control: Susan: "Her epilepsy has been well controlled for years now — she hasn't had a seizure in over two years, touch wood. The neurologist is happy with her on the Valproate. She takes it twice a day, morning and night, and she's very good with it."
●If asked about any recent seizures or falls related to seizures: Susan: "No, definitely not. She hasn't had a seizure in a long time. This isn't a post-seizure thing — she was absolutely fine when she went to bed on Monday night."
●If asked about how long she has been on Depo-Provera: Susan: "She's been on it since she was about 20, so over 12 years now. Her periods were horrendous — she'd have terrible cramps, heavy bleeding, and she'd get really distressed and have meltdowns. The Depo stopped all of that. It's been a lifesaver, honestly."
●If asked whether anyone has ever discussed bone health or DEXA scans: Susan: "No, nobody has ever mentioned anything about her bones. We just get the injection every 12 weeks and that's it. Should they have?"
●If asked about calcium or vitamin D supplements: Susan: "No, she doesn't take any supplements. Nobody has ever suggested she should."
●If asked about dysmenorrhoea before Depo-Provera: Susan: "Before the injection, her periods were awful. She couldn't understand what was happening to her and she'd be in so much pain. It would take days for her to settle afterwards. Starting the Depo was honestly the best decision we made."
●If asked about allergies: Susan: "No, she doesn't have any allergies that we know of."

Social History and Lifestyle Impact

●Chloe lives at home with Susan. She attends the Willow Day Centre on Mondays, Wednesdays, and Fridays, where she does art activities, cooking classes, and socialising with other adults with learning disabilities. It is the highlight of her week and gives Susan some respite.
●Susan: "She hasn't been able to go to the day centre since this started. She was supposed to go yesterday but she couldn't even get from the car to the front door without crying. She's been stuck on the sofa for two days and she's getting really frustrated — she keeps asking when she can go back and see her friends."
●Susan: "Even getting her upstairs to bed has been a nightmare. I've had to set up a mattress in the living room because she can't manage the stairs. I'm lifting her and she's a grown woman — I can't keep doing that on my own."
●If asked about exercise or mobility: Susan: "Normally she's really active — she loves her walks and she does a dance class at the centre on Wednesdays. She's not someone who sits still, so seeing her like this is really upsetting."

ICE — Ideas, Concerns, Expectations

The patient does not raise these unprompted. These surface only when the candidate directly explores Susan's (or Chloe's) perspective.

●Ideas: Susan cannot think of any physical explanation for the pain. Chloe hasn't fallen at home, hasn't done anything strenuous, and was fine on Monday evening. Because there is no obvious mechanical cause, Susan's mind has gone to the worst-case scenario — that someone at the day centre has hurt Chloe. She has no evidence for this, but the absence of any other explanation is fuelling the fear.
●Concerns: Susan is terrified that Chloe has been physically harmed by a carer or another service user at the day centre and that Chloe cannot tell her what happened. Beyond the immediate safeguarding fear, she is worried about what it means if Chloe can't walk properly — Chloe's independence, her access to the day centre, and Susan's own ability to physically manage Chloe's care at home alone.
●Expectations: Susan wants the doctor to take the pain seriously, examine Chloe properly, and arrange an X-ray or scan to find out what is actually wrong. She also wants the doctor to acknowledge that something unexplained happening to a vulnerable adult needs to be properly looked into — she needs to feel heard, not dismissed.

If Asked — Associated Symptoms

●If asked about pain at rest: Susan: "She seems okay when she's sitting still on the sofa, but the moment she tries to stand up or put weight on it, she cries out." Chloe: "It hurts when I stand up."
●If asked about pain at night or disturbed sleep: Susan: "She did wake up in the night on Tuesday — she was whimpering and trying to turn over. I think lying on that side hurts her."
●If asked about any back pain: Susan: "No, she hasn't complained about her back at all. It's all in the hip and groin area."
●If asked about any numbness or tingling in the leg: Susan: "No, nothing like that. She hasn't mentioned any pins and needles or anything going numb."
●If asked about knee pain: Susan: "No, her knee seems fine. It's definitely higher up — the hip area."
●If asked about being able to rotate or move the hip: Susan: "She can't really let me move it. If I try to turn her leg outwards she flinches and pulls away. I stopped trying because I didn't want to make it worse."
●If asked about any swelling, redness, or warmth over the hip: Susan: "No, I've had a good look and there's nothing visible. No redness, no swelling, no bruising."
●If asked about any recent weight loss: Susan: "No, her weight has been steady. She eats well — she's not a fussy eater."
●If asked about any fatigue or feeling generally unwell: Susan: "No, she's been her normal self apart from the leg. She's chatty, she's eating. It's just the walking."
●If asked about urinary symptoms or changes in continence: Susan: "No, she's been fine with that. No accidents, no pain going to the toilet."
●If asked about any previous fractures: Susan: "No, she's never broken anything before. She's always been quite sturdy."
●If asked about family history of osteoporosis: Susan: "My mum did have a hip replacement in her 70s, but I don't think anyone's been told they have thin bones or anything like that."
●If asked about smoking or alcohol: Susan: "Chloe doesn't smoke and she doesn't drink. Never has."

Negotiation & Collaborative Management Plan

●If the Doctor dismisses the abuse fear too quickly ("It's probably just a strain"):
●Reaction (Susan): Defensive. "A strain? From what? She hasn't done any heavy lifting! You aren't listening to me. Vulnerable adults get hurt all the time, I need you to take this seriously."
●If the Doctor diagnoses a potential fragility fracture (weak bones) due to the medications:
●Reaction (Susan): Shocked. "Weak bones? But she drinks milk! Are you telling me the injections the surgery has been giving her for ten years have damaged her bones? Why did nobody tell me this?"
●If the Doctor completely ignores Chloe and only talks to Susan:
●Reaction (Chloe): "I want to go home now. My leg hurts." (Testing the doctor's ability to re-engage the patient).
●If the Doctor says she needs to go to A&E for an X-ray:
●Reaction (Susan): "A&E is going to be a nightmare for her sensory-wise, but if you think her hip might actually be broken, I'll take her right now. Will they give her something for the pain?"

Safety Netting / Follow-up

●If the Doctor mentions reviewing the Depo-Provera later:
●Reaction (Susan): "Yes, we definitely need to talk about that injection when this is sorted. I don't want her on it if it's breaking her bones."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 26 indicators checked+0−0

Positive (0/13)

Negative (0/13)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Atraumatic Hip Pain in a Young Adult: Think Fragility, Not Strain

●An inability to weight-bear without any significant precipitating trauma in a young adult is not a soft tissue injury until proven otherwise — it is a fragility fracture until proven otherwise.
●The most important diagnosis to exclude is a fractured neck of femur (NOF) or pelvic fragility fracture, both of which can occur with no or minimal trauma when bone mineral density (BMD) is severely compromised.
●In this case, the combination of 12 years of continuous Depo-Provera and long-term Sodium Valproate creates a high-risk profile for iatrogenic osteoporosis — making a fragility fracture the most likely diagnosis despite the patient's age of 32.
●Systemic causes of acute hip pain must also be considered and actively excluded: septic arthritis, osteomyelitis, and occult malignancy each require a systemic screen (fever, weight loss, night sweats, inflammatory markers) before a mechanical/metabolic cause is assumed.

Depo-Provera and Bone Mineral Density: The 2-Year Threshold

●Medroxyprogesterone acetate (Depo-Provera) suppresses hypothalamic GnRH, leading to a hypo-oestrogenic state and consequent reduction in bone mineral density — a class effect that is dose-dependent and accumulates over time.
●FSRH guidelines are explicit: continuous use of Depo-Provera for more than 2 years in any woman requires formal reassessment of the risks and benefits, with particular attention to bone health. This is not a recommendation to stop at 2 years, but a mandatory review checkpoint.
●In adolescents and women under 18 (when peak bone mass has not yet been achieved), the FSRH advises that Depo-Provera should only be used when other methods are unacceptable. Chloe began Depo at age 20 — prior to full bone maturity consolidation — which compounds her risk.
●BMD reduction with Depo-Provera is partially reversible on cessation, but the extent of recovery depends on the duration of use and the patient's baseline bone health. After 12 years, significant residual deficit is expected.
●The clinical error here is the absence of any bone health review in over a decade of prescribing. The prescribing of Depo-Provera for menstrual suppression in women with learning disabilities is a recognised pattern that frequently goes unmonitored — this case represents a sentinel event.

Sodium Valproate and Bone Health: The Second Hit

●Several anti-epileptic drugs (AEDs), including Sodium Valproate, Carbamazepine, Phenytoin, and Phenobarbitone, are associated with reduced BMD and increased fracture risk through multiple mechanisms: induction of hepatic cytochrome P450 enzymes (for enzyme-inducing AEDs, though Valproate is a CYP inhibitor), increased vitamin D catabolism, direct effects on osteoblast activity, and secondary hyperparathyroidism.
●Valproate's contribution to bone loss is less well characterised than that of enzyme-inducing AEDs, but it is established in the literature and recognised in NICE and specialist epilepsy guidelines.
●In Chloe's case, Valproate and Depo-Provera are acting through independent mechanisms on the same endpoint — this is a genuine "double hit" to her skeletal health, and together they create a risk profile far exceeding either agent alone.
●Any change to Valproate must involve the neurology team. Seizure control has been excellent for 2+ years, but altering anti-epileptic therapy carries real risk and requires specialist oversight. The GP's role is to flag the bone health concern to neurology — not to initiate the change unilaterally.

Sodium Valproate and the PREVENT Programme

●Sodium Valproate is a major human teratogen, associated with neural tube defects, cardiac malformations, cleft palate, and neurodevelopmental disorders (including autism spectrum disorder and developmental delay) in exposed offspring, with a dose-dependent risk of around 10% for major congenital malformations at standard doses.
●The MHRA Pregnancy Prevention Programme (PREVENT) is mandatory for all women of childbearing potential prescribed Valproate in the UK. It requires: annual specialist review confirming the need for Valproate, documentation that two effective forms of contraception are in use (or that the patient has confirmed she will not become pregnant), and a completed patient acknowledgement form.
●In this case, the Depo-Provera is currently fulfilling the contraceptive requirement of the PREVENT programme. If Depo-Provera is discontinued, a robust alternative contraceptive must be in place before the change is made — the Valproate cannot be left without effective contraceptive cover, even temporarily.
●Capacity and consent are particularly important considerations here. Chloe has a moderate learning disability. The Mental Capacity Act 2005 requires that capacity is assumed unless there is reason to believe otherwise, and that decisions are made on a best-interests basis with the involvement of the patient and her carer where the patient lacks capacity for a specific decision. All discussions about contraception and Valproate must take place in this framework.

Acute Management: Urgent Imaging and Analgesia

●Same-day imaging of the hip and pelvis is required. A plain X-ray is the first-line investigation, but candidates must know its limitation: plain films can miss non-displaced or stress fractures, particularly in the context of osteoporotic bone in a younger patient.
●If the X-ray is normal and clinical suspicion remains high — a patient who cannot weight-bear with no alternative explanation — an MRI of the hip is the investigation of choice. MRI has superior sensitivity for occult fractures and can also detect avascular necrosis, bone marrow oedema, and soft tissue pathology.
●Depending on local pathways, same-day imaging typically requires referral to A&E or an acute assessment unit. The GP's role is to make the urgency clear in the referral and to prepare Susan and Chloe for what to expect.
●Analgesia before transfer: Chloe is in significant pain. Regular paracetamol (1g QDS) is appropriate as a baseline. A short-course NSAID (e.g., ibuprofen, if no contraindications) may be considered for acute pain, though NSAIDs have a modest negative effect on bone healing and should be time-limited. Codeine or low-dose opioids may be appropriate if paracetamol alone is insufficient — and Chloe's cognitive and communication level should inform how pain is assessed and monitored during transfer. Prescribing must account for her capacity to self-report.

Bone Health Investigation and Protection: The Follow-up Plan

●A DEXA scan (dual-energy X-ray absorptiometry) is the standard investigation for formal BMD assessment. It should be arranged once the acute injury is managed. The results will guide the need for bone-protective therapy (bisphosphonates or other agents) and provide a baseline for monitoring.
●Calcium and vitamin D supplementation should be commenced now, regardless of the DEXA result. Chloe has had no supplementation despite over a decade of dual bone-depleting medication, and supplementation is a safe, evidence-based baseline intervention in all patients with known risk factors for reduced BMD.
●Typical regimens include combined preparations such as Adcal-D3 (calcium carbonate 1.5g / vitamin D3 400 IU twice daily) or similar. Ensure adequate elemental calcium (at least 1000–1200mg/day total, dietary + supplemental) and vitamin D (at least 800 IU/day for bone protection in high-risk patients).
●If the DEXA confirms osteoporosis or significant osteopenia, bisphosphonate therapy (e.g., alendronic acid 70mg weekly) should be considered in liaison with the relevant specialists. Prescribing in a pre-menopausal woman of 32 with a learning disability requires careful multidisciplinary consideration.

Contraceptive Review: Safe Alternatives After Depo-Provera

●Once the acute fracture is managed and the DEXA result is available, the Depo-Provera should be reviewed with a strong presumption in favour of discontinuation. The clinical case for stopping is unambiguous given the duration of use, the fracture, and the FSRH guidance.
●The Levonorgestrel Intrauterine System (Mirena IUS) is the most appropriate first-line alternative for Chloe. It is highly effective, does not suppress systemic oestrogen (and therefore does not reduce BMD), reduces menstrual flow (typically producing amenorrhoea or very light periods), and requires no daily adherence — all critical advantages given Chloe's learning disability and the original reason Depo was prescribed.
●The progesterone-only pill (POP) is an alternative but requires daily adherence at a consistent time, which may be difficult to maintain.
●Combined hormonal contraception (CHC) would provide systemic oestrogen and could theoretically support BMD, but it is not required for bone protection and carries its own risk profile (VTE, cardiovascular). The IUS remains preferred.
●If IUS insertion is not tolerable due to pain, distress, or sensory difficulties, it can be performed under conscious sedation or general anaesthetic via community gynaecology or specialist sexual health services with learning disability expertise. This should be planned in advance and not deferred indefinitely.
●The contraceptive review should occur in the context of the PREVENT programme requirements — a documented plan for robust contraception must exist before any change to Valproate is considered.

Safeguarding: Holding Both Possibilities

●Unexplained injury in an adult with a learning disability who cannot fully self-report must trigger a safeguarding consideration, regardless of whether a medical explanation has been found.
●The GP's immediate duties are: (1) document the injury, the absence of a clear mechanism, and Susan's concerns in the clinical record; (2) ensure the receiving A&E or acute team are informed of the safeguarding context; (3) understand that a medical explanation (fragility fracture) does not automatically close the safeguarding question — non-accidental injury and bone fragility are not mutually exclusive.
●A local authority safeguarding referral under the Care Act 2014 may be warranted if, after full assessment, the cause of the injury remains unexplained or if any evidence of harm or neglect emerges. The decision to refer rests with the GP's professional judgement, made in consultation with the clinical record, the patient, and the carer.
●Key principle: Do not dismiss safeguarding because a medical cause has been found. Do not escalate to formal action before the clinical picture is complete. The correct position is to document, communicate, and hold the possibility open — then review after the imaging results.

Reasonable Adjustments for Hospital Attendance

●The Equality Act 2010 and NHS guidance require that reasonable adjustments are made for patients with learning disabilities in all healthcare settings, including acute care.
●As the referring GP, practical steps include: telephoning ahead to A&E to flag Chloe's learning disability and communication needs; providing a brief written hospital passport or handover letter that describes Chloe's communication style, sensory sensitivities, what helps her stay calm, and who is accompanying her; advising Susan to bring familiar comfort items.
●Requesting a quieter waiting area or learning disability liaison nurse input is appropriate where available.
●These adjustments are not optional extras — they reduce the risk of missed findings, undertreated pain, and deteriorating behaviour during what will be a highly stressful experience for Chloe.

Safety Netting and Follow-up

●Susan should be advised to return to A&E immediately if: Chloe develops fever or becomes systemically unwell (suggesting infection — septic arthritis, osteomyelitis); the leg becomes acutely more swollen, warm, or discoloured (suggesting vascular compromise or compartment syndrome); Chloe's pain escalates significantly.
●A GP follow-up appointment within one week should be arranged to: review imaging results; initiate or confirm calcium and vitamin D; begin planning the contraceptive review and DEXA scan; address the PREVENT programme documentation; consider referral to social services for carer support.
●Longer-term coordination across neurology (Valproate review), orthopaedics or rheumatology (bone health and bisphosphonate prescribing), gynaecology or sexual health (IUS insertion), and social services or the learning disability team (functional support and carer respite) will be required. The GP is the coordinating clinician for this multi-service plan.

Mapped to the RCGP curriculum topic: Learning Disability.

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