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You are an F1 working in a GP practice. Your next patient is a seventeen year old girl, Soraya Siss, who has presented to your surgery. She is known to have type 1 diabetes. She has an insulin pen, but no other regular medications.

Please take a history from Soraya and complete the appropriate examination. Please focus on the impact this condition has had on Soraya’s life. Following history and examination, you will be asked to discuss your findings with the examiner.

You are Soraya Siss, a seventeen year old girl who is really stressed out with exams right now. You definitely do not need what is going on with your health right now!

HPC: Last weekend you were getting ready for a party with your friends and one of your friends was straightening your hair for you. As she went to comb through your hair a large chunk fell out in her hand. It didn’t hurt and you didn’t realise until she told you what had happened. Since then, you have had chunks of hair falling out in the shower and when you brush your hair. You have woken up some mornings with hair on your pillow. Because your hair is so long you have been able to disguise the bald patches to some extent, but it’s getting worse and when you had to put your hair up for sports, you were really worried in case anybody noticed. The areas of hair loss are round, well-defined and the skin looks normal, with no redness or scarring. There are a few short, spiky hairs around the edge of the bald patches which look really ugly. The bald patches are not painful but sometimes they feel a bit “tingly”. You have noticed that you have also got some strange pits in your nail, which you have tried to cover up with nail varnish.

PMH: You were diagnosed with type 1 diabetes when you were 11 years old, after having a DKA and having to go into hospital. You take insulin every day and are generally pretty good at controlling your diet. Otherwise you are fit and well. You are up to date on all your immunisations.

DH and allergies: You take your insulin three times a day and you are normally quite good with your control. Recently you have started going to parties and drinking, and you know that this has messed with your blood sugars, especially because the drinks you like have a lot of sugar in them. You know you shouldn’t but if you are going out, you will sometimes take a bit more insulin to balance out the alcohol. Otherwise, you take no regular medication. You are allergic to penicillin and get a widespread itchy rash.

FH: You have an aunt who also has type 1 diabetes. Your mum has a thyroid problem, but you can’t remember which type it is.

SH: You live at home with your mum and little brother who is 15. Your parents are divorced and you see your Dad on weekends. Your Mum is a teaching assistant and your Dad works for a haulage company. There are no pets in the house. You are currently at college studying for A levels and you hope to go to university next year to study sociology. You enjoy college and have lots of friends. A levels are getting quite stressful and your Mum thinks this might be why your hair is falling out, but you don’t agree.

You go to parties most Saturday nights, where you will have a bottle of rosé or half a 50cl bottle of vodka with mixer. Often you will also have vodka jellies or shots of Sourz. You know it’s bad for your diabetes but you really enjoy letting loose while studying for A levels and you are worried what people would say if you said you couldn’t drink because of your diabetes. Not a lot of people at college know that you need insulin, only your close friends know in case you get ill, and you are worried that people would treat you differently if they knew. You have tried a few cigarettes but didn’t really like them. You have never taken any illicit drugs.

ICE: You are worried that you have started losing your hair because your blood sugars have been much worse since you started drinking. It’s really bothering you because it looks really ugly and people are starting to notice. Your hair is normally really long and you love being able to style it different ways; you really don’t feel yourself now that it is falling out. You’re really worried what people might say or think when they start to notice. You would like to know why this is happening and what you can do to stop it. You want to know if it will grow back.

Please observe the student take a history from this patient. A quality history will include eliciting ideas concerns and expectations regarding the impact this condition has had on Soraya’s life. Ask them to present their findings and list their differentials.

An example differential diagnosis would sound something like:

“My primary differential diagnosis would be a dermatological cause, more specifically alopecia areata. This is because of the history of patchy hair loss in a young person, on a background of type 1 diabetes, which has a proven link to alopecia. Other dermatological conditions to consider would be other forms of alopecia, such as androgenic alopecia and alopecia universalis, however these do not quite fit the pattern of hair loss or patient demographics. Moreover other causes of hair loss, such as tinea capitis, psoriasis and discoid lupus would need to be considered.”

Topics for discussion: • What is the pathophysiology of alopecia areata? • List some conditions associated with alopecia areata. • What advice would you give to this patient in regards to the hair loss? • What advice would you give to this patient in regards to her diabetes? • How might you manage this patient?