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This 44yr old lady, Mel Anoma, has presented to her GP feeling tired all the time. She has a PMH of depression and anxiety, PCOS and obesity. Her current medication includes Sertraline, and the COCP.

Please take a history from Mel and undertake the appropriate examination.

You are Mel Anoma, you are quite an anxious lady and are not overly talkative. You are unlikely to give the student a lot of information all in one go, especially when asked about things that don’t seem connected to your problem. You will be a bit more open when asked about your own ideas, as doctors don’t normally do this in your experience, and is a welcome change. You are very confident that this problem is not to do with your mood, although you are happy to talk about the problems you’ve over the years if pressed.

PC: Feeling tired all the time

HPC: Feeling just exhausted and worn out for the last month or so. You struggle to get out of bed in the morning, and no matter how much you sleep you never seem to feel refreshed. You’ve been having a lot of water infections recently, and at first thought it was all down to that. You haven’t had one for a while now though. Having said that, you’ve noticed you’ve been going to the loo an awful lot, especially at night. But you haven’t had any of the pain you normally get when you have a water infection, so it doesn’t feel like one of those to you. If asked about weight – you haven’t had any weight loss, despite trying your best. You’ve always been a big girl. If asked about bowel habit – very regular, no diarrhoea or constipation. Never noticed any bleeding from the bum either. If asked about skin changes – you haven’t noticed looking particularly tanned, although your armpits have looked really dark. Which is weird. If asked about mood – you’ve had problems with your mood in the best, but things have actually been good recently. The tablets you’re on are very helpful, and you’ve got a new boss at work who’s been much more supportive. So no, you don’t think its related to that really. DM complications – you’ve had no problems with your eye sight (if this has not been well signposted you will be very confused as to why they are asking about your eyes), never noticed any problems with the sensation in your feet. However, you have noticed that you’ve got a bit of an a sore on your foot over the last two weeks that has been very slow to heal. Its on the heel of your foot, and came from a blister from some new shoes. Thyroid - You haven’t had any problem feeling hot or cold. You’ve never noticed a tremor. You do occasionally get palpitations, but only when you’re getting really bad with your anxiety, and you haven’t had anything like that for over a year now.

ICE: Worried whether its anything to do with your hormones, you sister felt like this a few years ago and she had a problem with her thyroid in the end. You think you might just be being silly about that though, and think its most likely just recovering after yet another water infection. You were going to leave it until you spoke to your sister, and now you’re hoping you could get tested for your thyroid.

PMH: You’ve had several water infections over the last few months. You’ve had loads of different antibiotics and have a fridge full of cranberry juice. PCOS, had problems with your weight and periods for years and years. Only got to the bottom of it about when you started trying to have children. Depression and anxiety, went through a bad patch about 5 years ago when your mother died, but things have been much better over the last 18months. Obesity, always struggled with your weight, even though you try to have a healthy lifestyle. You always take the stairs rather than the elevator.

DH: Contraceptive pill (combined one) been on it since you were a teenager Sertraline Allergic to amoxicillin – had nausea and vomiting

SH: Lives with partner in flat. You don’t smoke and never have, and only rarely drink at Christmas or birthdays. Your diet isn’t great, you know you have a habit of comfort eating sometimes. But you do try your best to eat healthy, but you just find it so much easier to get ready meals. You currently work in the supermarket on the tills.

FH: Sister has low thyroid Diabetes runs in Dad’s side, type 2 you think. He was recently very unwell with it and had to go to hospital.

This is likely to be a more challenging history and the student may run out of time. They should ask a lot about the symptoms this lady may or may not be experiencing in order to rule out common causes. Having said that, this is NOT a mental health history. There is not necessarily an obvious examination to perform. However, an abdominal examination (or diabetic foot) would be most appropriate. The students differential diagnosis should sound something like this: ‘There are many potential causes for this ladies lethargy such as low mood, hypothyroidism or Cushings. However, my top differential would be diabetes due to her urinary symptoms, family history and background of PCOS’ Example topics for discussion could include: • Initial investigations for ‘tired all the time’ • Common differentials, how to rule them in or out • Diagnosis of diabetes • Management of diabetes • Differences between types of diabetes • Complications of diabetes • Management of diabetic emergencies • Risk factors for diabetes in this lady