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 Foundation Doctor working in General Practice. Your next patient is Denise Flynn, a 32-year-old female with lethargy. Please take a history and perform a relevant examination.
Patient History:
Denise Flynn, 32 y/o female, architect.
You have been feeling constantly fatigued over the last month. Although a lot is going on in your life at the moment (you are a new mother, after all), you have always been capable of adapting to challenging situations, so your recent lack of energy is completely out of character.
Being so fatigued all the time has impacted your life both at home and at work. You have found it increasingly difficult to concentrate on project work at the office. You frequently embarrass yourself in front of your clients when you forget simple details discussed moments earlier in conversation. Your lack of energy has limited your ability to help around the house, and you feel both you and your husband are being stretched thin. Despite the difficult times, you feel that your 6-month-old baby has brought a lot of joy to the household – your mood has been upbeat and optimistic in the face of your recent difficulties.
If asked, reveal that you have been feeling constipated recently and that your periods have been heavier than usual. You report no loss of interest in hobbies or low mood.
Ideas, Concerns, Expectations:
You think your symptoms could result from burnout from juggling childcare with a full-time job. You feel concerned as feeling tired all the time makes it very hard to take care of your 6-month-old. You would like your symptoms investigated as soon as possible.
Past Medical History:
Type 1 diabetes
Drug History:
Insulin.
No known drug allergies.
Family History:
Both of your parents had heart attacks when they were in their 60s. Deny any family history of thyroid disease.
Social History:
Non-smoker.
Before you were pregnant, you were a social drinker: you used to have the occasional gin and tonic on nights out with your friends. Nowadays, most of your free time is devoted to childcare, so drinking alcohol has become an afterthought.
No recreational drug use.
Live at home with husband and a 6-month-old child.
Recently returned to work as an architect.
Examination Findings:
A thyroid examination is most appropriate.
The patient is dressed in thick clothing.
A pulse rate of 55 bpm can be detected.
If reflexes are tested, they are slow to relax.
If an inspection of the patient’s hair or skin is carried out, reveal they are both dry in quality.
Further examination will reveal the absence of:
Neck swelling or bruits
Retrosternal goitre
Ocular manifestations of thyroid disease, including periorbital oedema
Differentials:
Postpartum thyroiditis causing hypothyroidism
Anaemia contributing to fatigue
Other differentials to consider:
Postnatal depression
Primary hypothyroidism e.g. Hashimoto’s thyroiditis (generally presents at an older age), Atrophic thyroiditis, Iodine deficiency, Subacute thyroiditis
Secondary hypothyroidism e.g. TSH deficiency
Postpartum thyroiditis may manifest clinically as either hyperthyroidism or hypothyroidism. It is an autoimmune disorder associated with other autoimmune diseases like type 1 diabetes mellitus. Remember to consider the possibility of non-organic causes of fatigue e.g. postnatal depression.
Investigations:
Bedside:
ECG (The dose of levothyroxine needs to be reduced in patients with ischaemic heart disease. Serial ECGs are useful in aiding up-titration in these patients)
Bloods:
FBC + iron studies/b12/folate (anaemia can cause tiredness)
Thyroid function tests (low T4, High TSH – primary hypothyroidism)
Thyroid antibodies e.g. serum thyroid peroxidase antibodies (TPOAb) may be found – these antibodies can also be found in Hashimoto’s thyroiditis or Graves’ disease.
Urea and electrolytes - (hypothyroidism can cause euvolemic hyponatraemia)
Lipid panel (hypothyroidism is associated with hypercholesterolemia)
Glucose/ hba1c (diabetes/poor control can cause tiredness)
Vitamin D (low vitamin can cause tiredness)
Bone profile (low calcium can cause tiredness)
Consider imaging of the thyroid +/- biopsy and imaging of the pituitary/hypothalamus if indicated.
Management: