Woman Phoning for Her Dexa Scan Result — Free SCA Practice Case
Woman phoning for her DEXA scan result
Station Timer
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
Materials for Candidate
Please review before starting the consultation
Full Name
Maureen Ellis
Age
70 years
Consultation Type
TelephoneAge
70
Situation
Telephone Consultation. Booked to discuss DEXA scan results.
Reason for Encounter
"I've phoned to get my bone scan results. I broke a bone in my back a couple of months ago and was sent for the scan."
Medical Records
- ●PMH: Osteoarthritis. Hypertension. Urge incontinence.
- ●Medications: Paracetamol PRN, amlodipine 10 mg OD, mirabegron 50 mg OD, codeine PRN.
- ●Allergies: NKDA.
- ●Orthopaedics letter (~6 weeks ago): Mechanical fall → L2 vertebral compression fracture; no red flags; conservative management; asks GP to assess bone health for osteoporosis.
- ●DEXA result: Lumbar spine T-score −0.9; total hip −1.0; femoral neck −1.0 (all in the normal range; normal ≥ −1.0, osteopenia −1.0 to −2.5, osteoporosis ≤ −2.5).
Patient Script
For the friend playing the patient role
Character Overview: You are Maureen, a 70-year-old retired hairdresser. A couple of months ago you slipped in your living room reaching for the TV remote and fractured a bone in your back (a vertebra); it was managed with pain relief, and your GP sent you for a bone-density (DEXA) scan. You are phoning for the results. Your back pain is now controlled and you have no leg weakness or bladder/bowel problems. You are a heavy smoker (about 40 a day for 40 years). You reached the menopause at 49 and did not take HRT. You eat a reasonable diet with dairy, and you walk for exercise but do no strength training. You are not especially worried and just want to know the results.
Opening Sentence: "Hello Doctor. I'm ringing for my bone scan results. I broke a bone in my back a couple of months ago — slipped reaching for the remote — and you sent me for the scan. I feel much better now. What did it show?"
History if Asked (Data Gathering Phase)
- ●The fracture: "I slipped in the living room reaching for the remote and hurt my back. They said I'd fractured a bone in my spine. It's much better now with the painkillers."
- ●Red-flag check: "No weakness in my legs, no problems with my waterworks or bowels, and the back pain's well controlled now."
- ●Menopause/HRT (if asked): "The change was at 49. I never took HRT."
- ●Smoking (if asked): "I smoke about 40 a day — have done for about 40 years."
- ●Diet/exercise (if asked): "I eat a balanced diet with dairy. I walk regularly but I don't do any weights or strength work."
- ●What she wants: "Just to hear my results, really. I wasn't sure what to expect."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.
- ●Ideas: Maureen has no firm idea what the scan will show and may assume a "normal" result means her bones are fine. "I don't really know what to expect — I suppose if the scan's normal, my bones are okay?"
- ●Concerns: She has few overt concerns and is fairly relaxed; part of the task is helping her understand she is nonetheless at risk. "I'm not especially worried, to be honest."
- ●Expectations: She expects to be told her results. "I just want to know what the scan showed."
If Asked — Fracture-Risk and Cause Screen
The patient answers these only when directly asked.
- ●If asked about previous fractures: "No, just this one."
- ●If asked about family history of osteoporosis/fractures: "None that I know of."
- ●If asked about steroid use or other bone-affecting medication (e.g. long-term PPI): "No steroids, and no, I don't take anything like that long term."
- ●If asked about alcohol: "I don't drink much."
- ●If asked about falls/balance/mobility: "Just the one slip. Otherwise I'm steady and independent."
- ●If asked about calcium/vitamin D/diet and exercise: "Balanced diet with dairy; I walk but don't do strength training."
- ●If asked about early menopause/HRT: "Menopause at 49, no HRT."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains that, despite a 'normal' scan, the fracture means osteoporosis: "But you said the scan was normal — so how can I have osteoporosis?" (The tested point is explaining that a fragility fracture indicates clinical osteoporosis regardless of the DEXA number.)
- ●If the Doctor explains her fracture risk: "So I'm more likely to break more bones? Even though the scan looked okay?" (The tested point is explaining fracture risk clearly.)
- ●If the Doctor recommends a bisphosphonate: "You want me to take a tablet for my bones — how long would I be on it?" (The tested point is bisphosphonate counselling, including how to take it and duration.)
- ●If the Doctor raises smoking cessation: "My smoking affects my bones too? I've smoked for years." (The tested point is addressing smoking as a major modifiable risk.)
- ●If the Doctor advises on calcium/vitamin D and exercise: "Is there anything else I should be doing — diet, exercise?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
A Fragility Fracture Means Clinical Osteoporosis
- ●A fragility fracture (a fracture from a fall from standing height or less, or a vertebral compression fracture) in an older person indicates clinical osteoporosis and warrants bone-protective treatment — regardless of the DEXA T-score. Do not be falsely reassured by a "normal" or osteopenic DEXA in the presence of a fragility fracture.
DEXA and Diagnostic Thresholds
- ●On DEXA, normal is a T-score ≥ −1.0, osteopenia −1.0 to −2.5, and osteoporosis ≤ −2.5. DEXA quantifies bone density but does not override the clinical significance of a fracture.
Fracture-Risk Assessment
- ●Use FRAX or QFracture to estimate fracture risk and guide treatment, integrating risk factors: age, prior fracture, smoking, alcohol, steroids, early menopause, family history, and low BMI.
Bisphosphonate Counselling
- ●Alendronate is first-line: take weekly, on an empty stomach with a full glass of water, remain upright for ~30 minutes, before food/other medicines. Counsel on GI/oesophageal side effects, the rare risks (osteonecrosis of the jaw, atypical femoral fracture), a dental check, and review after ~3–5 years. Ensure calcium and vitamin D adequacy.
Modifiable Risk Factors — Especially Smoking
- ●Smoking is a major modifiable risk for osteoporosis and fracture (and general health) — advise cessation with support. Advise on calcium, vitamin D, and weight-bearing/resistance exercise, and falls prevention.
Secondary Causes
- ●Consider blood tests and screening for secondary causes of osteoporosis where appropriate (e.g. calcium, vitamin D, and other tests as indicated).
Communicating a Counter-Intuitive Result
- ●The core communication challenge is explaining that a "normal" scan does not mean healthy bones when a fragility fracture has occurred — clearly, reassuringly, and persuasively enough to secure treatment.
Common Candidate Mistakes in This Case
- ●False reassurance from the DEXA: missing clinical osteoporosis because the T-score is "normal."
- ●Not offering bone protection: failing to treat a fragility fracture.
- ●Poor bisphosphonate counselling: omitting administration instructions, side effects, or duration/review.
- ●Ignoring smoking and lifestyle: missing major modifiable risks and falls prevention.
- ●Confusing the patient: delivering the "normal scan but osteoporosis" message in a bewildering way.