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You are an FY1 working in a GP surgery. Your next patient is Guy Nee, a 55-year-old gentleman who has come in for his regular ‘well man check’. He is known to be overweight. Her current medications are: Enalapril OD, Atorvastatin OD, Aspirin OD The nurses have recorded a recent height and weight as 109kg and a height of 1.75m, yielding a BMI of 36. Please take a targeted history from this man. You will then be asked to discuss the case with the examiner.

You are Guy, a 55-year-old white man who works as an actuary. You live with your wife and have 3 older children who have left home. HPC: You’ve just come in for your regular check but there are a few things you want to ask about. You’re feeling ok but have been really quite tired for the last few months. You’re still going to work but you get back and don’t feel like you can do anything. On weekends you’ve found yourself not having the energy to do more than just sit and watch TV. You do get a little breathless, especially when walking uphill. Sometimes you have to stop halfway up a steep hill. You never get breathless at rest and never get breathless lying flat or at night time. You have also noticed that your vision hasn’t been as good as it has been. You have had difficulty focusing on the papers at work, it all seems slightly more blurry than usual. It has all come on very gradually, you haven’t had any sudden loss. You haven’t had any floaters, pain or redness in your eyes. You were going to go to the opticians but seeing as you had this appointment first you thought you would get it checked out to make sure nothing serious was going on. You haven’t had any recent weight loss- you wish!- but have put on a few pounds recently. You haven’t had any chest pain, cough or wheeze. You don’t experience any pain in your calves. Your waterworks have been fine. You have had no palpitations and don’t feel feverish. You haven’t had any dizziness or loss of consciousness. You haven’t had any particular aches and pains. You have not had any recent travel. Your mood has been really good at the moment; you’re scheduled a holiday in Bali with your wife next month! You’ve never had any problems with your mood. ICE: You think the medications you’ve been on may have caused your tiredness. You’re worried that your eyesight may interfere with your life and work. You’ve got the regional golf title to defend after all! You’re hoping the doctor can take a look at your medications list or give you something to help with the tiredness if the medications aren’t the cause. PMH: You have high blood pressure. DH: Enalapril, Atorvastatin, Aspirin. You don’t take anything over the counter. You are allergic to penicillin. FH: A lot of family members are overweight, you think it must ‘be in the genes’. Your father had diabetes and died of a heart attack at 60. Your mother also has diabetes and had a ‘mini stroke’ when she was in her sixties. Your brother has high blood pressure. SH: You describe your diet as very poor. You admit you snack on lots of sugary treats throughout the day as it’s often hard for you to have the time to eat a proper meal. By the time you eat dinner in the evening, you are famished and tend to overeat. Your wife has been trying to make you eat more fruit and vegetables, cooking meals like meat and two veg, but you have found this difficult. Your work is always busy and quite stressful. You can’t remember the last time you exercised because you’ve found even walking up hills tough for the last few months. You smoked for about 1 year when you were in your twenties. You probably smoked a pack a day. You have about a glass of wine a day. You have never taken any recreational drugs.

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 type 2 diabetes with metabolic syndrome in due to the patient’s obesity, history of hypertension and family history of diabetes, in addition to symptoms of fatigue and poor vision. I would also consider physiological fatigue in addition to age related presbyopia or other unrelated visual loss. Other differentials would include endocrine causes of the fatigue and weight gain such as Cushing’s disease and autoimmune causes of fatigue of visual changes such as Sjogren’s, though these are unlikely. Topics for discussion may include: What bloods tests might an NHS check-up include? What are some of the causes of fatigue? What are some of the clinical signs of metabolic syndrome? How would you manage a patient with metabolic syndrome?