Station 67
Margaret Collins
Age: 68 years old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
Ask specific follow-up questions for each of the patient’s reported symptoms:
Nails: When did the ridges start? Any changes in colour, texture, or shape of the nails?
Knee pain: Was the pain related to any activity or injury? Any swelling, redness, or stiffness?
Abdominal discomfort: Where exactly is the pain? Is it getting worse? Any change in bowel habits or PR bleeding?
Back pain: Does it improve or worsen with rest or movement? Any bowel or bladder changes?
Hair thinning: When did this begin? Any recent stress, illness, dietary change, or new medication?
Ask about cancer red flags: unintentional weight loss, night sweats, loss of appetite (Note: loss of appetite may also relate to grief or low mood)
Explore social history: how she’s coping emotionally since her husband’s death, availability of family or social support, impact on daily life
Ask about sleep, and whether symptoms are affecting her routine or functioning
Ask if she has accessed any form of bereavement counselling or emotional support
Explore ICE (ideas, concerns, expectations) to better understand her fears and what she hopes to achieve from the consultation
Give a working diagnosis of grief-related anxiety with somatic symptoms or health anxiety following bereavement.
Example of explanation to patient
Margaret, I can see you’ve been through a lot recently with the loss of your husband, and it’s understandable to feel worried about your health, especially given what he went through. From the investigations we’ve done so far, everything looks reassuring, which is a good sign.
Now, while we haven’t found anything medically worrying, I don’t for a second think your symptoms aren’t real. What I suspect is happening here is that grief and emotional stress may be playing a part in how your body is feeling. This is something we call a grief reaction with physical symptoms, and it’s something we see quite often in people who’ve experienced significant loss.
That said, I want you to know that I’m here to support you. Let me re-assure you that your symptoms are unlikely due to pancreatic cancer.
Let’s go through your symptoms one by one so we don’t miss anything:
- The ridges or lines on your nails are something we commonly see with age, but they can also appear during or after times of stress or illness. Your iron levels were checked and found to be normal, which is reassuring, as low iron can sometimes be linked to nail changes.
- The knee pain you had sounds like a one-off episode that may have been due to strain or wear and tear in the joint, which can happen as we get older. It’s encouraging that it settled quickly. Simple pain relief and staying gently active usually help with that.
- The back pain you’ve described doesn’t sound worrying either. It’s very common and can happen from posture, tension, or changes in activity. Keeping gently mobile, stretching, and using paracetamol if needed often helps.
- Your tummy discomfort is also reassuring, especially as your bowel tests, including FIT and calprotectin, were normal. That helps rule out more serious causes like inflammation or cancer.
- Hair thinning can be linked to stress and emotional upset. After a difficult time, the body can go through a shedding phase. This is called telogen effluvium, and it often settles down on its own as things start to stabilise again.
So although you’ve had a number of symptoms, none of them on their own, or taken together, suggest anything dangerous, and your test results back that up.
Does all of that make sense so far?
Like I mentioned earlier, I’m not saying your symptoms aren’t real, they absolutely are, but it does mean we might be looking at your body’s way of processing stress and loss.
Would you be open to a bit of support with that? There are bereavement services we can refer you to, or we could connect you with our social prescriber, who can help you gently get back into social or community activities when you feel ready.
We’ll keep a close eye on things, and of course, if anything changes or you notice any new symptoms, you should get in touch, and we’ll review things again. You’re not on your own in this.
How does all that sound to you?
Management
Management
- Reassure the patient that her symptoms are not concerning based on recent normal investigations, and take a symptom-specific approach
- Nail ridges: Reassure that these are common with age or can be stress-related; ferritin levels were normal, which helps rule out iron deficiency
- Knee pain: Likely mechanical or linked to osteoarthritis; advise gentle movement, regular activity, and consider paracetamol as needed
- Abdominal discomfort: Reassure her that both FIT and calprotectin were normal and there are no red flag symptoms; continue to monitor
- Back pain: Likely mechanical in nature; recommend gentle stretching, pacing of activities, and maintaining mobility
- Hair thinning: Reassure that this may be stress-related (telogen effluvium); advise monitoring and offer review if it persists or worsens
- Explore and offer support for bereavement, such as local bereavement counselling services, support groups, or referral for CBT if symptoms of health anxiety persist
- Encourage gentle re-engagement with activities she enjoys, such as gardening or community groups; consider referral to the social prescriber for additional local support
- Safety net: Advise her to contact the practice urgently if she develops new or worsening abdominal symptoms (e.g. persistent pain, a lump, diarrhoea, PR bleeding), sudden worsening of back pain, or visual changes such as an increase in floaters or flashes of light
Learning point from this station:
This station highlights the importance of recognising grief-related somatic symptoms while ensuring that potential underlying medical causes are not overlooked.
Patients who have experienced recent bereavement or emotional distress may present with a wide range of vague physical symptoms, such as fatigue, pain, hair thinning, or gastrointestinal discomfort. These can be expressions of grief, stress, or health anxiety, particularly when routine investigations are normal and symptoms are non-specific.
However, it is essential to avoid prematurely attributing symptoms to psychological causes without appropriate clinical assessment. If the patient has not had recent blood tests, investigations should be considered to rule out common reversible causes such as anaemia, thyroid dysfunction, B12/folate deficiency, or inflammatory conditions.
A sensitive explanation may include:
“It sounds like you’ve been through a very difficult time, and grief or anxiety can understandably affect both your mind and your body. But it’s also important that we don’t miss anything else. Conditions like low B12, thyroid problems, or vitamin deficiencies can cause similar symptoms, and we can pick these up with some simple tests.”
Good clinical practice involves exploring both the emotional and physical dimensions of the presentation, offering support through bereavement counselling or social prescribing, while using investigations appropriately to maintain safety and patient trust.