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You are an FY1 working in a GP surgery. Your next patient is Steven, a tall slim 20-year-old man who has come in due to a maternal diagnosis of thyroid cancer. He is not currently on any medication. Please take a targeted history from this man. You will then be asked to discuss the case with the examiner.

You are Steven, a 20-year-old man who is currently studying French at university. You live in a flat with 4 other students. HPC: You were told to get yourself checked out by one of the doctors that looks after your mum. Your mum was diagnosed with aggressive thyroid cancer last year and had her thyroid removed. She had a lump in the middle of her neck and some smaller lumps up her neck for a number of years previous to this. You think the type started with an ‘m’- medial thyroid cancer maybe? If asked, your mum has never been exposed to any radiation that you are aware of. You feel really well in yourself and have always been in good health. You’ve always stuck out a little bit, being tall and having lumpy lips, but you figured you just took after your mum. You’ve had the lumpy lips since you were probably 5 or 6. They haven’t gotten bigger, maybe just grown with you. You’ve never had any dislocations and it hasn’t bothered you. You haven’t had any chest pain, breathlessness, cough, hoarseness or wheeze. You haven’t had any recent weight loss. Your bowels and waterworks have been fine. You haven’t had any abdominal pain. 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 noticed any skin changes. You have not had any recent travel. You haven’t had any visual changes. You have had a lot of headaches recently, but think that is probably just stress related to everything that’s been going on with your Mum. The pain is like a pressure all over your head. You’ve also noticed you’re sweating a lot, even when you’re not doing anything. It’s getting a little embarrassing to be honest. ICE: You think that you have the same condition that your mum has as you have been told that it is an inherited condition. You are not that close to your mum so do not know the name of the condition. You only know that you should get checked. You are concerned about your bumpy lips, eyelids and tongue which your mother also has. You were always told you take after her, but this is one thing you dread having in common. You think they may be the start of the thyroid cancer. You’re hoping you can have a scan like your mother did to rule out the worst. PMH: You have never had any health problems, only a couple of broken bones and you dislocated your hip when you were younger. DH: You are not on any medications and do not have any allergies. FH: You are not close to your mother’s side of the family, but you have not heard about any conditions that run in the family. Your grandma and aunt on your dad’s side had breast cancer in their mid-fifties. A lot of your father’s family have diabetes. They don’t inject insulin though. SH: You keep fit and well. You play on the national ultimate frisbee team and can’t afford to take much time off. Your tall slim build sets you up nicely to catch those high passes! You smoked for about 1 year when you were in your teens. You probably smoked a couple of cigarettes a day. You have tried cannabis a couple of times. You are a ‘typical student drinker’. You go out maybe a couple of times a week and ‘get smashed.’ You don’t know how much exactly you drink.

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 Multiple Endocrine Neoplasia, specifically MEN-2b, with a family history of medullary thyroid cancer as well as a potential marfanoid body habitus and lumpy lips. Other genetic syndromes such as other subtypes of MEN, Marfan’s and FAP are also possible. It may be that the thyroid cancer is sporadic. Topics for discussion may include: What the clinical signs of Marfan’s syndrome? What are some risks associated with Marfan’s syndrome? What are some common inherited endocrine conditions? What are some differentials for neck lumps?