Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in family medicine. Your next patient is Sally O'Reilly, a 35-year-old female who always feels tired. Please take a history and perform a relevant examination.
Patient History:
Sally O’Reilly, 35y/o F, shop assistant.
Lately, you've been feeling tired throughout the day on most days. Life has been difficult for you since this all started 4 months ago. You complain that although you have the motivation to go out and do things – you still look forward to the weekends when you have the time to do gardening; after all – you just don't have the energy to make things happen. You've tried sleeping more to replenish your energy, but you've found that it hasn't made much of a difference.
Over the last year, you have noticed that you've been prone to short bouts of loose stools but have never noticed any blood mixed in. You remark that it's strange how your stools seem to float on the water. You've noticed an itchy, red rash over both your elbows and knees that appeared a week ago. You have also noticed that you get bloated after meals (particularly those heavy on bread and pasta), making you aware of some mild abdominal discomfort.
You have not noticed any significant weight loss. You have not gone through menopause.
Ideas, Concerns, Expectations:
Before you were diagnosed and treated for hypothyroidism, you had a similar experience of long-lasting fatigue, so you wondered if your recent symptoms could represent a recurrence of your thyroid disease.
Past Medical History:
Confirmed past Hashimoto’s thyroiditis, well-controlled.
Past appendicectomy.
Drug History:
Levothyroxine – good compliance.
No recent antibiotic use.
No known drug allergies.
Family History:
No history of cancer or abdominal problems.
Social History:
Do not smoke, drink or do recreational drugs.
Work as a shop assistant.
Examination Findings:
Redness at both angles of the mouth.
Pale conjunctiva.
2 ulcers on the insides of the mouth.
A red, vesicular rash over both elbows and knees
No abdominal tenderness or masses on palpation
No jaundice
And no other significant abnormalities.
Differentials:
Coeliac disease
Irritable bowel syndrome
Hypothyroidism
This history and the associated examination are suggestive of coeliac disease. The vesicular rash, in this case, is dermatitis herpetiformis, a skin disease strongly related to coeliac disease. The patient's background of autoimmune thyroid disease puts her at risk of developing other autoimmune diseases like coeliac disease. It is important to remember that coeliac disease can present for the first time at any age.
The tiredness and exertional dyspnoea with the associated pale conjunctiva and angular stomatitis found on examination suggest a component of iron-deficiency anaemia complicating the clinical picture.
Investigations: