Long-term Tiredness Previously Treated for Vitamin D Deficiency — Free SCA Practice Case

Character Overview: You are Deborah, a 48-year-old woman who has felt exhausted for months. You were found to be low in vitamin D and treated, but the tiredness has not lifted. You are convinced there must be a physical cause and want more blood tests. You have not connected your tiredness to your mood, though when gently asked you will acknowledge you have been low, tearful, and have lost interest in things. You are not seeking a mental-health conversation and may be initially reluctant or slightly defensive if it is raised clumsily. If it is raised sensitively, you will open up.

Opening Sentence: "Hi Doctor. I'm still shattered all the time — no energy at all, even after a full night's sleep. I had low vitamin D and took the treatment, but it's made no difference. I really think something physical must be going on, so I've come to get my bloods checked again."

History if Asked (Data Gathering Phase)

• ●The tiredness: "It's been months — maybe six or more. Exhausted all day, no energy, everything's an effort. Sleep doesn't refresh me. If anything it's got worse."
• ●Sleep (only if asked): "I fall asleep okay but I wake really early — like 4 or 5am — and can't get back off. I just lie there."
• ●Mood (only if gently explored): "I suppose I have been low, now you ask. Tearful for no reason. I've stopped seeing friends and doing the things I used to enjoy — I just can't be bothered. I hadn't really put it together as being connected to the tiredness."
• ●Life circumstances (if explored): "It's been a hard year. My marriage broke down, my youngest went off to university so the house is empty, and work's been stressful. I've been keeping going but I feel flat and worn down."
• ●What she wants: "I want to find out what's physically wrong. I assumed it was the vitamin D, and when that didn't work, I thought maybe it's my thyroid or something in my blood."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Deborah is firmly looking for a physical explanation — she assumed vitamin D, then wonders about thyroid or "something in the blood." She has not connected her symptoms to depression, and may resist the idea if it is put to her bluntly. "In my head this is physical — vitamin D, or my thyroid, or my blood. I hadn't thought it could be my mood, and honestly I don't love the suggestion."
• ●Concerns: She is worried there is a serious physical illness being missed, and feels frustrated that treating the vitamin D did not help. Underneath, she is worn down and a little frightened by how flat she feels. "I'm worried something serious is being missed. And I'm scared by how low and empty I feel, if I'm honest."
• ●Expectations: She expects more blood tests and a physical answer. "I came for blood tests and a physical explanation."

If Asked — Mood, Risk, and Physical Screen (approached sensitively)

The patient answers these only when directly and sensitively asked.

• ●If asked about low mood, anhedonia, tearfulness: "Yes — low, tearful, no interest in things I used to enjoy."
• ●If asked about early-morning waking, appetite, concentration: "Early waking, yes. Appetite's down, I've lost a bit of weight. I can't concentrate."
• ●If asked about guilt, worthlessness, hopelessness: "I feel a bit useless and hopeless about things, yes."
• ●If asked, sensitively, about thoughts of self-harm or that life isn't worth living: "I've had moments where I've thought what's the point… but I wouldn't do anything. I've got my kids. I'd never act on it." (Passive thoughts, no intent or plan, protective factors present. Assess sensitively; no method detail is sought or given.)
• ●If asked about thyroid symptoms (cold intolerance, weight gain, constipation): "Not really — no weight gain, if anything I've lost a bit; no feeling cold or constipated."
• ●If asked about anaemia symptoms (breathlessness, palpitations, heavy periods): "No breathlessness or palpitations. Periods are getting irregular — I think I'm heading into the menopause."
• ●If asked about alcohol: "A glass or two of wine most evenings lately — more than I used to, to switch off."
• ●If asked about what physical tests she's already had: "The vitamin D, and I think thyroid and blood count were done and were fine six months ago."

Responses to Management (The Negotiation Phase)

• ●If the Doctor sensitively raises low mood/depression as a cause: "Depression? But I came about being tired — you think it's all in my head?" (The tested point is reframing sensitively — validating that the tiredness is real and physical in its effects, and explaining that depression genuinely causes physical exhaustion — without her feeling disbelieved.)
• ●If the Doctor still offers to check bloods: "So you will check my bloods as well, not just tell me it's my mood?" (The tested point is not missing organic disease — offering an appropriate physical screen alongside recognising depression.)
• ●If the Doctor explains the sleep pattern: "The early waking — that's linked to mood? I thought it was just the tiredness."
• ●If the Doctor discusses treatment options: "So what would help? I'm not sure about tablets, and I don't know if I've got time for therapy."
• ●If the Doctor safety-nets: "What should I do if I feel worse?"