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You are an FY1 working in a GP surgery. Your next patient is Sarah, a 58 year old lady who has come in complaining of aches and pains. 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 Sarah, a 58-year-old dinner lady. You live with your wife and have no children- you see enough of those at work! HPC: You have come in because you have been having constant aches and pains in your back and legs for a number of months. If asked specifically, it has probably been about 4 months. The pain is a generalised dull ache that doesn’t spread anywhere else. It seems to be there all of the time in the background although it seems a little worse in the morning. It gets better after 10-20 mins of getting up. You would rate the pain about a 3/10 and paracetamol can put a dent in it, but you don’t want to have to take paracetamol all the time. You have also been feeling quite low for the last number of months. Usually you’re a pretty cheery person; you thought initially it might be because of the dark winter months but it has persisted. You also feel like you have less energy and have been a little more irritable than usual. You still are able to do everything you want to do however and have not had any suicidal thoughts. You haven’t experienced periods of very high mood. You have also had on and off abdominal pain over the last couple of months. It comes on every few days. It has been a generalised dull 2/10 ache that hasn’t spread anywhere. Paracetamol helps and nothing makes it worse. You haven’t experienced any stiffness, redness or swelling in any of your joints. You haven’t suffered any recent injuries. You haven’t had any chest pain, cough or wheeze. Your bowels and waterworks have been fine. You have had no palpitations and don’t feel feverish. You have not had any recent travel or weight loss. You went through menopause 4 years ago. You are currently sexually active. ICE: Last month you had two kidney stones and one of the doctors told you one of your bloods tests was quite high. You think you are waiting for a referral to see a specialist doctor about this. You wonder if this pain could be related to your blood results. You’re worried that you might be developing arthritis and that if might interfere with your job and everyday living. You’re hoping that the doctor can recheck your blood results and explain what they might mean. 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 3 years ago. You had two kidney stones last month which didn’t need any surgical intervention. DH: Verapamil, Atorvastatin. You don’t take any vitamin supplements or anything else over the counter. No known allergies. FH: There is no family history of autoimmune conditions or problems with the joints, apart from your mother having some osteoarthritis. There is no family history of kidney stones or endocrine conditions. You have never had any cancers. SH: You live in a bungalow with your wife. You have no problems at home. You have never smoked. You regularly alcohol very occasionally. You have never taken any recreational drugs. The pain has put you off doing as much physical activity as you would usually do.

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 hypercalcaemia most likely due to primary hyperparathyroidism, due to the history of generalised aches and pains, low mood, abdominal pain and kidney stones. I would also consider depression which can cause systemic symptoms. Other differentials would include statin use, which may explain the aches and pains but is unlikely to explain the low mood, although this may be unrelated; and malignancy, which is unlikely due to the lack of red flag symptoms. Topics for discussion may include: What bloods might you request and what would they show? What are the most common causes of hypercalcaemia? What causes would you be worried about and what would be their red flag symptoms? What might the options be for management of primary hyperparathyroidism?