“I’m worn out all the time, doctor”

Candidates: do not open until you have consulted.

Persona and manner

• Angela Campbell, 52, home care worker — you drive between clients’ houses, six or seven visits a day. Married to Trevor; two grown-up children. Warm, stoical, a bit embarrassed to be “wasting an appointment on being tired”.
• Yawn once or twice. You look weary rather than unwell.

Opening line — say this verbatim

• “I’m worn out all the time, doctor. I think it must be the change — I just need a tonic or a blood test or something.”

Volunteer freely if given the space

• Tired for about eight months, and getting worse. You wake up feeling as if you have not been to bed.
• You have started having a nap in the car between clients most afternoons — twenty minutes — and you fall asleep in front of the television by eight.
• Your periods stopped just over a year ago; a few hot flushes, not many now.

Only if asked

• Sleep: in bed by ten, up at six; no night shifts — the same hours for years. You wake two or three times — sometimes with a dry mouth, often to pass water, and once or twice with a jolt, “as if I’d been holding my breath”.
• Snoring: always a bit; much louder over the last year. Trevor moved into the spare room three months ago. If asked whether anyone has noticed your breathing stop: “Trevor says I go quiet and then snort — he used to nudge me to start me off again.”
• A dull headache most mornings, gone by ten o’clock. You are getting forgetful — you missed a client’s lunchtime tablets last month, which is not like you.
• Weight: up about eight kilos in two years since you stopped your exercise class — too tired to go. Collar size up on your uniform.
• Family: your dad “snored like a train” and had a machine with a mask at night in his sixties; your brother Gary has just been given one.
• Mood: fed up and irritable with the tiredness, but not low — you still enjoy your grandchildren and your church choir. No loss of interest. Not anxious.
• No heavy bleeding before your periods stopped; no bleeding since. No feeling cold, no constipation, no change in hair or skin. No thirst. No weight loss, no night sweats, no breathlessness, no chest pain. Bowels normal.
• Alcohol: a glass of wine at the weekend. No sleeping tablets or sedating medicines. Two coffees a day — and more recently an energy drink at about three o’clock “to get me through”.
• Driving: about 60 miles a day for work in your own car, on an ordinary car licence. Keep the traffic-lights story back unless you are asked directly whether you have ever felt sleepy or nodded off at the wheel, or had an accident or a near miss — see the ‘anything to add’ line.

Impact on daily life — home and work (only if asked)

• You dread the afternoon visits; you have started turning down extra shifts, and money is tight.
• Trevor sleeping in the spare room upsets you both.
• You have stopped choir practice on Thursdays because you cannot stay awake; you nodded off at your granddaughter’s school play.

Ideas, concerns and expectations

• Idea: the menopause — or that you are “low on iron”.
• Concern: that you are getting dementia like your mum — the forgetfulness frightens you. And that you are letting your clients down.
• Expectation: a blood test and a tonic; perhaps HRT.

Cues to deliver, timed

• Minute 2: “Trevor’s in the spare room now — says I sound like a tractor.” (Said with a laugh; if the doctor does not pick it up, do not repeat it.)
• Minute 4, if sleepiness when driving has not been asked about: “The afternoons are the worst — I have to pull over for a nap between clients.”

If the doctor summarises and asks whether you want to add anything

• If the traffic-lights story has not come out — whether or not driving has been mentioned: “There is one thing — last week I think I nodded off at the traffic lights. The van behind beeped and woke me up. I haven’t told anyone — I can’t do my job without the car.”
• If it has: “Could it be dementia? Mum started by forgetting things.”

How to respond to the doctor

• If the doctor explains that your breathing is probably being interrupted many times a night, that this explains the tiredness, the headaches and the forgetfulness, and that it is treatable: relieved — “So it’s not my mind going?”
• If told not to drive: upset — “Who’s going to get my ladies up in the morning? Six people depend on me.”
• If the doctor acknowledges that, explains that it applies until the sleepiness is under control, asks the sleep clinic to see you quickly because you drive for work, and offers a fit note or a letter to your employer: you agree — reluctantly — to stop driving until you have been seen and treated.
• If the doctor is vague (“be careful driving”, “take breaks”): you carry on driving.
• If the doctor orders blood tests and says nothing else: you thank them and leave none the wiser.
• If offered HRT, a tonic or antidepressants for the tiredness: you accept.

Do not

• Volunteer the snoring detail, the pauses in breathing, your father’s mask machine or the traffic lights unless asked — or invited to add anything (apart from the timed cues).
• Use the words “sleep apnoea”.

Findings to give the candidate — only if asked for

If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Domain marks — with the key facts that earn a 4 at this station

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory   ☐ Borderline   ☐ Satisfactory   ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. NICE NG202 — assess for obstructive sleep apnoea/hypopnoea syndrome when a person has two or more of: snoring, witnessed apnoeas, unrefreshing sleep, waking headaches, unexplained excessive sleepiness, tiredness or fatigue, nocturia, choking during sleep, sleep fragmentation or insomnia, cognitive dysfunction or memory impairment (rec 1.1.1). It is more common with obesity, treatment-resistant hypertension, type 2 diabetes, atrial fibrillation, hypothyroidism and other conditions (rec 1.1.2).
2. Women with sleep apnoea are more likely than men to report fatigue, insomnia, morning headache and low mood, and less likely to report snoring or witnessed apnoeas — so they are under-diagnosed; prevalence rises sharply after the menopause (Bonsignore and colleagues, European Respiratory Review 2019; NICE CKS lists post-menopausal women as a risk group).
3. Use the Epworth Sleepiness Scale in the assessment (0–10 normal; 11–12 mild, 13–15 moderate, 16–24 severe sleepiness), and consider STOP-Bang (hers is 6 of 8 — high risk) — but do not use the Epworth score alone to decide on referral, because not everyone with sleep apnoea is sleepy (NICE NG202 recs 1.1.3–1.1.4).
4. The referral letter (NICE NG202 rec 1.2.1) should give the assessment scores, how sleepiness affects the person, comorbidities, occupational risk and the oxygen saturation — add the BMI and the driving history. The sleep service prioritises for rapid assessment people with a vocational driving job or a job where vigilance is critical for safety, unstable cardiovascular disease (including treatment-resistant hypertension), pregnancy, pre-operative assessment for major surgery, or non-arteritic anterior ischaemic optic neuropathy (rec 1.2.2). NICE does not define “vocational driving job”, and the DVLA uses “vocational” for Group 2 (lorry and bus) licences — so do not call her a vocational driver: write that she holds an ordinary (Group 1) licence, drives about 60 miles a day between clients, cannot work without driving, and gives medicines to vulnerable adults — a job where vigilance is critical for safety.
5. DVLA (Assessing fitness to drive, ‘excessive sleepiness’): a person with excessive sleepiness that has, or is likely to have, an adverse effect on driving — including suspected sleep apnoea — must not drive until the symptoms are controlled. They must notify the DVLA if control is not achieved within three months; if moderate or severe sleep apnoea syndrome with sleepiness is confirmed they must not drive and must notify. Relicensing then needs control of the condition, improved sleepiness and adherence to treatment, confirmed medically, with review at least every three years for Group 1 (car) and every year for Group 2 (lorry and bus). Mrs Campbell holds an ordinary car licence, so Group 1 standards apply even though she drives for work. Driving against medical advice may also invalidate motor insurance.
6. The doctor’s duties (GMC, Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA): explain that the condition may affect safe driving and that she has a legal duty to tell the DVLA when the rules require it; tell her — as information, not as a threat — that a doctor may be obliged to inform the DVLA if a patient carries on driving when unfit; record the advice. If a patient continues to drive, cannot be persuaded to stop, and others are exposed to a risk of death or serious harm, the doctor contacts the DVLA medical adviser in confidence — trying to tell the patient beforehand, and confirming in writing afterwards. A fit note (“may be fit for work” with amended duties) is the standard route for work; a letter to an employer is private work, so an F2 checks with the supervising GP.
7. Diagnosis is by a sleep study — usually home respiratory polygraphy (NICE NG202). Severity by apnoea–hypopnoea index: 5 to under 15 mild, 15 to under 30 moderate, 30 or more severe. Treatment: CPAP for moderate and severe disease, and for mild disease when symptoms affect quality of life and daytime activities; a mandibular advancement splint as an alternative for some; weight loss, less alcohol, stopping smoking and sleep hygiene for everyone; positional devices in selected people.
8. Bloods for prolonged fatigue (NICE CKS; NICE NG20): FBC, ferritin, ESR or CRP, renal and liver function, TSH, HbA1c and coeliac serology (IgA tissue transglutaminase); bone profile, urinalysis and others as the history directs. They run alongside the referral — a normal result does not explain an Epworth score of 16. Other causes of sleepiness to keep in mind: too little sleep, sedating drugs and alcohol, restless legs, depression, hypothyroidism and — rarely — narcolepsy.
9. Untreated sleep apnoea is associated with hypertension that is hard to control, atrial fibrillation, stroke and road traffic collisions. Treating it improves sleepiness and quality of life, and may help blood pressure a little. Her blood pressure is uncontrolled on two drugs — not yet “resistant”, which NICE NG136 defines as uncontrolled on three; the next step is a third drug after checking adherence and home readings.

Where candidates lose marks at this station

• Bloods and a follow-up — and no sleep history.
• “It’s probably the menopause.”
• Never asking a tired person whether they drive.
• “Try to take breaks when you’re driving.”
• Waiting for normal blood results before referring.
• Missing the husband in the spare room.

Guidelines for this station

• NICE NG202 — Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s
• DVLA — Assessing fitness to drive: excessive sleepiness, including obstructive sleep apnoea syndrome
• GMC — Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA
• NICE CKS — Obstructive sleep apnoea syndrome
• Asthma + Lung UK — Obstructive sleep apnoea (patient information)

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-18