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You are an FY1 currently on placement at a GP surgery. Your next patient is Amy Nophiline, a 40-year-old banker who has come today as she has lost about a stone in weight over the last month. She has no other past medical history of note. Please take a history and perform a relevant examination.

You haven’t really been trying to lose weight, and haven’t changed anything about your diet or exercise regime. However you have been feeling a lot more peckish recently, usually wanting more at dinner, and snacking more often during the day- nothing seems to fill you up! You’ve also started feeling a bit flushed a lot of the time, particularly when you’re in hot places, but you figured that due to your age you are probably just going through the change of life as your periods have also become really irregular, and this hasn’t really bothered you.

Another strange thing you’ve realised is that your hair has started to become quite thin and straggly, and even falls out a bit more than usual. You’ve heard coconut oil can make hair thicker again so you’ve been trying that but it hasn’t helped.

You’ve also noticed your heart racing sometimes, like you’ve just run a marathon! This is a bit weird, and you have to sit down for a bit to recover from these episodes. You’re also a bit more shaky than normal. You feel quite on edge now you think about it, sleeping poorly, like you can’t switch off. You put this down to work becoming a bit more stressful of late. However you haven’t experienced any changes in your mood- you are still pretty content with how life is going for you!

You’ve noticed a bit of diarrhoea recently, but there’s never any blood or mucus in it. You’re not going to the toilet any more often than usual to pass urine. One very weird thing that you’ve noticed is that your eyes feel really uncomfortable, like they’re always dry and gritty. You’ve not noticed any double vision, and you don’t think that your eyes look any more bulgy than usual (what a strange question, doctor!) You haven’t noticed any lumps in your neck, and you don’t feel any more thirsty than normal.

ICE: You’re only really here today because Theo is worried about your health. His sister was recently diagnosed with colorectal cancer, and before that she lost a lot of weight too. However you feel so well, you don’t think it’s that, but you suppose that thoughts do niggle in the back of your mind. You aren’t sure what to expect from today’s appointment- the things that have been happening are so varied, and affecting multiple body parts you sort of think maybe you have a lot of different conditions, and that you’re falling apart.

PMH: None significant

DH: None Allergic to penicillin

FH: Mum had something wrong with a gland in her neck, you can’t remember what exactly though Brother has Coeliac Disease

SH: You live at home in a terraced house with your husband Theo, also a banker. You have two children, Alex and Tom who are 11 and 13, both in good health. Your mother and father live quite close by and are pretty well given their ages. You work full time, and your symptoms haven’t stopped you going to work- you hate missing days! You smoke 10 cigarettes a day, and have done for about 20 years, apart from when you were pregnant with your boys. You drink alcohol socially- a couple of large glasses of wine per week with dinner.

The student should take a detailed history eliciting all of the symptoms that Amy is experiencing, and asking questions pertaining to endocrine, psychiatric and gastrointestinal causes of weight loss. A thyroid examination (neck examination) would be acceptable in this case but a GI exam could also be performed.

Differential Diagnosis

My differential diagnosis would include hyperthyroidism, and causes of this, particularly Graves’ disease as Amy is experiencing some thyroid eye symptoms. There is a family history of autoimmune disease, and she is in an at-risk demographic, being a female in her 40s. Other endocrine causes, such as diabetes, are less likely as there is no polydipsia or polyuria. Colon cancer could be considered in the differential due to the weight loss and change in bowel habit.


What are the causes of hyperthyroidism? What are the signs and symptoms of thyroid eye disease? What investigations would be appropriate in this case? What pattern of thyroid function tests would you expect to find? What are the management options for Amina? What is a thyrotoxic crisis?