Station 70
Priya Patel
Age: 56 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
Acknowledge that the patient was reviewed by a colleague with symptoms of palpitations, sweating, weight loss, and menstrual irregularities, and was sent for blood tests. Ask whether her symptoms have worsened since the last consultation, then proceed with a structured head-to-toe review for hyperthyroidism.
For example: Hi Priya, I can see from the notes that you saw my colleague recently because you’d been experiencing symptoms like a racing heart, sweating, weight loss, and changes to your periods, and you were sent for some blood tests. Before we go over those results together, can I check, have any of your symptoms worsened since your last appointment? After that you can say, “I would like to ask you a few quick questions from head to toe to get a fuller picture of how things have been”
- Ask about eye symptoms, including blurry vision, excessive tearing, or light sensitivity (photophobia)
- Ask about any neck swelling or visible/enlarged thyroid gland
- If neck swelling is present, ask for compression symptoms: difficulty breathing, hoarse voice, trouble swallowing (dysphagia), or a feeling of pressure in the neck.
- Ask about the palpitations, when they occur, how long they last, and whether they’re getting worse.
- Ask about presence of hand tremors —If present, ask when they’re most noticeable (e.g. at rest or during activity).
- Ask whether she feels hot when others are cold, suggestive of heat intolerance.
- Ask about any fever, which may suggest thyrotoxicosis.
- Ask about fatigue or tiredness.
- Ask about bowel symptoms, particularly diarrhoea.
- Ask about menstrual irregularities, including the current amenorrhoea
- Ask about mood changes, irritability, or difficulty sleeping.
- Ask how the symptoms are affecting her daily life, including work or social function
- Ask about social history, including work, home, lifestyle
- Ask whether she is on contraception or actively trying to conceive
- Explore ICE — ideas, concerns, and expectations
- Give a working diagnosis of hyperthyroidism
Example of explanation to patient
Priya, thank you for coming in to follow up. I’ve had a look at your blood test results, and they confirm that your symptoms; the palpitations, weight loss, sweating, and changes to your periods, are due to a condition called hyperthyroidism, or an overactive thyroid.
Is that something you’ve heard of before?
The thyroid is a small gland in the front of your neck that is responsible for controlling energy levels and body functions. When the gland is overactive, it causes your body to go into “overdrive.” That’s why you’ve been feeling more on edge, losing weight without trying, and noticing changes in your periods.
Now, the good news is that this condition is treatable, and there are very effective ways to manage it. The first step is to help settle some of your more uncomfortable symptoms, like the hear tracing (palpitations) and tremor. For that, we can start a medication called propranolol, which acts quite quickly to calm those symptoms down. Are you okay with tablets?
I will also be discussing and referring you to a specialist team- endocrinology (hormone doctors) who manage thyroid conditions. They will arrange an appointment to see you in clinic but meanwhile, they’re likely to suggest we start you on a medication called carbimazole, which works by reducing the amount of thyroid hormone your body is making.
There are just a couple of important things to be aware of with carbimazole. In rare cases, it can affect the white blood cells that help fight off infections. So, if you ever feel feverish, unwell, or develop a sore throat, it’s really important to contact us straight away. It can also, though very rarely, affect an organ in the tummy called the pancreas, so if you develop unexplained tummy pain, again, please don’t ignore it, just let us know and we’ll get it checked. I know this is a lot of information so far, have you got any questions?
You also mentioned that you’re hoping to start a family soon. Because an overactive thyroid that isn’t well controlled can affect pregnancy, increasing the risk of things like miscarriage or problems with the baby’s development, we would recommend waiting to conceive until your thyroid levels are back in the normal range.
In the meantime, I would suggest the use condoms as a temporary form of contraception, just to be on the safe side. If you would like, we can book a separate appointment to talk through other reliable forms of contraception options that suit your plans and preferences.
How are you feeling about all of this so far? Is there anything you would like me to go over again or explain differently?
Management
Management
- Offer propranolol (If no contraindications) to help relieve adrenergic symptoms such as palpitations, tremor, and agitation.
- Offer an ECG, especially in patients with cardiovascular symptoms such as palpitations, chest discomfort, dizziness, or shortness of breath, to screen for atrial fibrillation, a recognised complication of hyperthyroidism.
- Refer to endocrinology, as per NICE guidance, for all patients with newly diagnosed hyperthyroidism
- Explain that you will liaise with endocrinology regarding starting carbimazole, a medication used to treat overactive thyroid
- Counsel on carbimazole side effects, including agranulocytosis: Advise the patient to seek urgent medical advice if they develop sore throat, fever, or flu-like symptoms, as this may indicate a drop in white blood cells. Pancreatitis: Advise to report any new or unexplained abdominal pain immediately
- If eye symptoms (e.g. visual changes, discomfort, proptosis) are present, refer same day to ophthalmology
- Arrange a repeat TSH and thyroid function test in 6 weeks, then every 3 months until stable
- Advise the patient not to conceive until their thyroid levels are stabilised (euthyroid), due to increased risks of miscarriage and fetal abnormalities
- Recommend condoms as interim contraception, the offer a follow-up consultation to discuss more reliable contraceptive options
- Refer to endocrinology not only for diagnosis but also to help with pre-pregnancy planning and ongoing management
- Safety net: Advise the patient to seek urgent medical advice if they develop worsening symptoms such as chest pain, shortness of breath, severe palpitations, or signs of thyroid eye disease
Learning point from this station:
In women of reproductive age, untreated hyperthyroidism can have significant implications for both fertility and pregnancy. It is important to advise any woman with newly diagnosed hyperthyroidism and intention to conceive, to delay conception until her thyroid function has normalised. Poorly controlled hyperthyroidism in pregnancy increases the risk of miscarriage, preterm birth, foetal growth restriction, and congenital abnormalities.