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You are an FY1 working in a GP surgery. Your next patient is Dee, a 61-year-old woman who has come in complaining of weight gain. Her current medications are: Verapamil OD, Atorvastatin OD. Please take a targeted history from this woman. You will then be asked to discuss the case with the examiner.

You are Dee, a 61-year-old retired radiographer. You currently live alone since your husband died 5 years ago. HPC: You have gained a lot of weight over the last few months even though you have had little appetite. If asked, you have probably gained at least 10 pounds in the last 6 months despite eating less than ever before. You’ve never had any problems with your weight before this. You’ve also been feeling quite tired for the last 6 months too, even though you have found yourself sleeping more than ever. You’ve been needing to sleep 12 hours a day and have 4-6 cups of coffee to keep yourself awake. You feel like you’ve suddenly gotten old, you seem to spend a lot of time sitting shivering in your armchair! It does seem to have gotten quite chilly recently… If asked about specific symptoms: You have experienced some constipation over the last couple of months. You normally go to the toilet without any trouble so this is new for you. You feel quite low which is probably because you haven’t had much sleep. You haven’t thought about taking your own life. Your skin has been quite dry for the last few months, as if you’ve developed eczema when you’ve never had it before. You haven’t been sexually active so haven’t noticed any change in your sex drive. Your best friend commented that you’ve been speaking slower than usual, and that your voice is lower as if you’ve got a sore throat. You think it’s just because you’ve been feeling so tired. You haven’t had a sore throat of a cough at all so it’s probably nothing. If asked, you do feel like your neck might be a bit swollen at the front but you thought maybe its just the weight gain. You haven’t had any chest pain, cough or wheeze. Your waterworks have been fine. You have had no palpitations and don’t feel feverish. You haven’t had any particular aches and pains. You have not had any recent travel. You went through menopause about 10 years ago. ICE: You have no idea why you might be putting on so much weight and feeling so tired. You know it can’t be because of your diet because you’ve hardly been eating anything! You’re worried it might be something serious. You saw an advert online saying that ovarian cancer can cause bloating. You want to know why you’re gaining weight and hope the doctor might be able to prescribe something to help you lose weight. PMH: You don’t have any problems with your health. If asked specifically, you have been told you have hypertension and high cholesterol for which you were put on some medications about 8 years ago. You have never had any cancers. DH: Verapamil, Atorvastatin. You don’t take anything over the counter. No known allergies. FH: There is no family history of autoimmune conditions or problems with the thyroid and kidney. There is no family history of diabetes. Your grandmother had bowel cancer in her 70s. SH: You live alone in a bungalow since your husband died 5 years ago. You have no problems at home. You have never smoked. You never drink alcohol. You have never taken any recreational drugs. You feel like the lack of energy is really interfering with your life and you feel self-conscious going out in public because of your weight.

Please observe the student taking a history from this patient. You should ask them to present their findings to you, with a list of possible differentials. An ideal list of differentials would look something like: “My primary differential diagnosis would be hypothyroidism, due to the history of systemic disease including weight gain, low energy, constipation, and cold intolerance. I would also consider depression which can cause systemic symptoms. Other differentials would include ovarian cancer which may cause GI symptoms and fatigue, and Cushing’s syndrome due to the low energy and weight gain. Topics for discussion may include: How would you investigate these symptoms? What are some common causes of hypothyroidism? What are some of the clinical signs of Graves’ disease? How would you manage a patient with hyperthyroid disease?