ℹ️ This is the case information for the doctor.

Name

Sarah Harris

Age

Address

25 Mill Lane, Cranford

Social history

Non-smoker.
Alcohol 8 units / week

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Past history

Coeliac disease, diagnosed 7 years ago.

Anxiety for several years, managed with sertraline.

Current dose has been stable for 3 years.

GORD / reflux, increasingly troublesome and controlled with lansoprazole since last year.

Investigation results

Blood Results — Last Week

Thyroid: TSH 32.7 ↑, free T4 6.4 ↓ — consistent with overt primary hypothyroidism.
FBC / iron: Hb 134, ferritin 54 — not anaemic.
Coeliac: tTG IgA <3 — negative.
FSH: 5.3 — within premenopausal range; early menopause less likely.
Lipids: Total cholesterol 5.7 ↑.
Liver: ALT 22 — within range.
Renal: eGFR 100 — normal.
Glucose: Random glucose 4.9 — within range.
Pulse: 64 bpm, regular.

Medication

Sertraline 100 mg once daily.
Lansoprazole 30 mg once at night.
No other regular medication.
No known drug allergies.

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Booking note

Tired all the time

ℹ️ This is the information for the person role playing the patient.

Case overview

Name

Sarah Harris

Age

Address

25 Mill Lane, Cranford

Social history

Non-smoker.
Alcohol 8 units / week

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Past history

Coeliac disease, diagnosed 7 years ago.

Anxiety for several years, managed with sertraline.

Current dose has been stable for 3 years.

GORD / reflux, increasingly troublesome and controlled with lansoprazole since last year.

Medication

Sertraline 100 mg once daily.
Lansoprazole 30 mg once at night.
No other regular medication.
No known drug allergies.

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Opening statement

“I've just been feeling so exhausted lately. I can’t keep up with everything; my periods are heavier, and I’m just struggling to get through the day.”

Information freely divulged

Initial information given in response to a general opening question

Sarah says she has been increasingly tired over the last 6–8 months, with the tiredness becoming much worse over the past 2–3 months.
She gets through most days at work but feels exhausted by late afternoon.

Information given in response to follow up open questions

Keeping the house running and looking after the children and dogs feels overwhelming.
Her periods have become much heavier and now last about a week rather than 4–5 days.
She sometimes passes clots, which is unusual for her.
She feels cold indoors, especially in her hands and feet, despite the central heating.
She has dry, itchy skin on her arms and shins, and her hair is becoming coarser.

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Information given on questioning

Symptoms:

She tries to walk the dogs most days but struggles for energy.
She has unintentionally put on 4 kg over the last few months despite eating as usual.
She has no new gut symptoms and maintains a strict gluten-free diet.
She has noticed slight tingling or numbness in her hands at times, especially at night.
She has been more constipated than usual and opens her bowels every other day.
She has no nausea, vomiting or rectal bleeding.
She has tried to get more rest, but it makes little difference.
She has no eye symptoms

Lifestyle information

Non-smoker.
Drinks 3–4 glasses of wine per week, usually at weekends.
Works part-time as a secretary at a local law firm.
Lives with her partner, two children aged 7 and 11, and two Labradors.
Recently caring for her elderly mother, who has mobility issues.
Tries to walk the dogs most days but currently struggles because of tiredness.
Pays for her own gluten-free foods and finds family expenses a strain.
Her partner is supportive but busy with work.
Has friends through school mums and work.

Family history information

Her mother has hypothyroidism and has taken levothyroxine for as long as Sarah can remember.
No family history of early menopause, heart disease or Type 1 diabetes.
No family history of coeliac disease other than Sarah herself.

Medical history information

Coeliac disease diagnosed 7 years ago; Sarah maintains a strict gluten-free diet.
Anxiety for several years; she takes sertraline, with the current dose stable for 3 years.
GORD / reflux treated with lansoprazole since last year.
No previous thyroid issues noted.
No surgeries.
No other regular medication.
No known drug allergies.
Most recent tTG antibodies are negative.

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Behaviour

Initial disposition and manner

Present as clearly exhausted and low in energy.
Be polite and open, and visibly anxious about your health and your ability to manage your responsibilities.
You may appear overwhelmed when discussing home, work and caring duties.
Do not immediately volunteer every concern about medication, cost or family history unless the clinician asks or builds rapport.

Emotional triggers and shifts

If the clinician sensitively asks how you are coping or mentions your mother, you may become tearful but grateful for the opportunity to talk.
If the clinician acknowledges the strain of caring, parenting, housework and work, become more engaged.
If the clinician is dismissive, says it is “just stress”, ignores medication fears or brushes off cost concerns, become frustrated and withdrawn.
If the clinician focuses only on test results without acknowledging the effect on your life, you may disengage.

Response to clinical explanations

You are likely to feel relieved if the blood results are clearly explained and connected to your symptoms.
You want the numbers explained and may ask for clarification about what they mean.
You may feel anxious when told that treatment is likely to be long-term.
You need reassurance that levothyroxine is not addictive and understand that it replaces a hormone your body is lacking.

Response to clinical management and proposals

You are open to treatment if it is explained clearly.
You are worried about taking tablets for life, medication dependency and cost.
If cost is discussed, you may ask: “Is it a prescription charge or will it be like my gluten-free foods I have to pay for?”
You appreciate practical information about monitoring, side effects, follow-up and support.
If the consultation goes well, finish feeling relieved, hopeful and more confident about treatment.
You appreciate a clear summary of the diagnosis, medication plan, monitoring, cost implications and safety-netting.
You may value written or online information to review later.

Key role-player instructions

Do not introduce clinical facts that are not provided in the case.
Do not volunteer all concerns about thyroid medication, cost or family history at the start; disclose them when asked or when rapport has been established.
Become tearful if the clinician sensitively explores coping, caring responsibilities or the impact on family life.
If the clinician is dismissive or brushes off your practical concerns, become frustrated and withdrawn.
If the clinician explains the results clearly, addresses medication concerns and cost, and offers practical support, become relieved, hopeful and engaged.

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ℹ️ To mark data gathering & diagnosis select from the descriptors below.

Positive descriptors

Negative descriptors

Makes effective use of existing information and considers the wider context:

Reviews and integrates the recent blood results, including TSH 32.7, Free T4 6.4, non-anaemic status, total cholesterol 5.7, normal tTG IgA and normal-range FSH, and connects them with Sarah’s symptoms and context.

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Makes effective use of existing information and considers the wider context:

Fails to reference or integrate key results from the notes, or misses the relevance of Sarah’s coeliac history, family history, cholesterol result and psychosocial stressors.

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Establishes relevant red flags and risk features:

Screens for severe hypothyroid complications and the clinical significance of menorrhagia, including symptoms such as cognitive impairment, myopathy, severe fatigue, dizziness, syncope, breathlessness, chest pain or palpitations.

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Establishes relevant red flags and risk features:

Neglects to screen for severe hypothyroid complications or the impact of menorrhagia, and does not clarify symptoms such as dizziness, syncope, breathlessness, chest pain, palpitations, confusion or severe functional decline.

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Places the problem in its psychosocial context:

Elicits the impact of fatigue and heavy periods on Sarah’s work, parenting, dog walking, household tasks, caring for her mother, emotional wellbeing and finances.

Places the problem in its psychosocial context:

Does not ask how symptoms affect Sarah’s job, parenting, housework, dog walking, caring responsibilities, anxiety or financial worries.

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Reaches a working diagnosis using a structured, evidence-based approach:

Links symptoms, autoimmune and family background, and thyroid function tests to support the working diagnosis of primary hypothyroidism.

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Reaches a working diagnosis using a structured, evidence-based approach:

Fails to connect the symptoms, risk factors and biochemical results into a coherent diagnosis, or misses the possible autoimmune context.

Considers relevant differential diagnoses for tiredness:

Contextualises the likely causes of the thyroid disturbance in light of the differential diagnosis. Autoimmune, thyrotoxic nodule, goitre, thyroid cancer.

Considers relevant differential diagnoses for tiredness:

Fails to contextualise the likely causes of the thyroid disturbance in light of the differential diagnosis. Autoimmune, thyrotoxic nodule, goitre, thyroid cancer.

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Revises hypotheses in light of additional information:

Moves beyond initial possibilities such as stress, anaemia, menopause or coeliac relapse when the thyroid results and family history indicate overt hypothyroidism.

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Revises hypotheses in light of additional information:

Sticks rigidly to explanations such as stress, anaemia or menopause despite clear thyroid dysfunction in the supplied results.

ℹ️ To mark clinical management & medical complexity select from the descriptors below.

Positive descriptors

Negative descriptors

Offers safe and appropriate management options:

Explains primary hypothyroidism and discusses levothyroxine replacement, individualised dosing, medication review, monitoring and safety-netting for inadequate response or over-replacement.

Offers safe and appropriate management options:

Does not discuss thyroid hormone replacement, gives an unsafe or vague medication plan, omits individualisation or monitoring, or dismisses treatment despite overt hypothyroidism.

Empowers self-care and patient involvement:

Provides understandable information about hypothyroidism, encourages symptom monitoring, reinforces gluten-free diet, discusses lifestyle measures as tolerated and explains when Sarah should seek review.

Empowers self-care and patient involvement:

Provides little education about the condition or medication, gives no advice on symptom monitoring or lifestyle, and fails to explain when Sarah should seek help.

Uses referral appropriately and avoids unnecessary specialist input:

Recognises that straightforward new primary hypothyroidism can usually be managed in primary care, while identifying situations where specialist advice may be needed, such as pregnancy, age under 18 or diagnostic uncertainty.

Uses referral appropriately and avoids unnecessary specialist input:

Refers to endocrinology without clinical indication, or arranges excessive investigations such as scans or pituitary imaging when the diagnosis is straightforward from the supplied information.

Practises holistically and promotes wider health:

Addresses cholesterol, coeliac disease, anxiety, carpal tunnel-type symptoms, heavy periods, home pressures, carer strain and prescription cost concerns as part of the plan.

Practises holistically and promotes wider health:

Focuses only on the thyroid result and ignores Sarah’s anxiety, financial constraints, caring role, heavy periods, coeliac disease or functional impact.

Manages patient uncertainty and medication concerns:

Explains that levothyroxine is hormone replacement rather than an addictive medication, clarifies likely long-term treatment, and discusses expected symptom improvement and consequences of not treating.

Manages patient uncertainty and medication concerns:

Fails to acknowledge fears about medication dependency, gives vague or conflicting explanations, or leaves Sarah unsure why treatment is recommended.

Tailors the management plan to Sarah’s circumstances:

Arranges monitoring, follow-up, information and support in a way that considers Sarah’s work, parenting, caring responsibilities, financial worries and preference for clear numerical explanations.

Tailors the management plan to Sarah’s circumstances:

Gives a generic plan without addressing prescription costs, monitoring practicalities, work, family commitments or support with caring responsibilities.

ℹ️ To mark relating to others select from the descriptors below.

Positive descriptors

Negative descriptors

Tailors the management plan to Sarah’s circumstances:

Gives a generic plan without addressing prescription costs, monitoring practicalities, work, family commitments or support with caring responsibilities.

Tailors the management plan to Sarah’s circumstances:

Gives a generic plan without addressing prescription costs, monitoring practicalities, work, family commitments or support with caring responsibilities.

Communicates in a person-centred way:

Validates Sarah’s exhaustion and acknowledges the effect on work, family life, parenting, caring for her mother and emotional wellbeing.

Communicates in a person-centred way:

Focuses only on the medical facts and ignores Sarah’s emotional distress, exhaustion and the impact on her responsibilities.

Treats Sarah’s concerns with respect:

Takes seriously Sarah’s worries about lifelong medication, addiction, financial pressure and the extra burden of paying for gluten-free food.

Treats Sarah’s concerns with respect:

Dismisses Sarah’s worries about dependency, medication costs, lifelong tablets or gluten-free food expenses.

Supports informed decision-making:

Explains levothyroxine, likely treatment duration, monitoring and prescription cost issues clearly enough for Sarah to ask questions and make an informed choice.

Supports informed decision-making:

Fails to explain the need for treatment, expected duration, monitoring or cost implications, leaving Sarah uncertain or misinformed.

Works collaboratively to plan care:

Agrees a monitoring and follow-up plan with Sarah that fits around her work, caring responsibilities, family life and support needs.

Works collaboratively to plan care:

Imposes a generic treatment and review plan without asking about Sarah’s preferences, availability, family pressures or practical barriers.

Checks understanding of the consultation and plan:

Summarises the diagnosis, blood results, treatment rationale, monitoring plan and cost information, and checks whether Sarah wants anything repeated or clarified.

Checks understanding of the consultation and plan:

Gives information without checking Sarah’s understanding or inviting questions about the blood results, medication, monitoring or costs.

ℹ️ Insights from the examiner

📝 Section 1: Case Overview and Consultation Priorities

Case at a glance

Sarah Harris is 38 and presents with progressive fatigue, heavier periods and symptoms affecting her work, family life and caring responsibilities. Her results show TSH 32.7 mU/L and Free T4 6.4 pmol/L; the case identifies this as overt primary hypothyroidism. The consultation also needs to address her concerns about long-term medication, “addiction”, cost and practical follow-up.

GP trainee performance focus

A strong GP trainee should connect Sarah’s symptoms with the thyroid results, explain the findings clearly and explore the impact of her symptoms without reducing the consultation to a discussion of laboratory values. The trainee should respond to Sarah’s concerns, agree a practical treatment and monitoring plan, and make the next steps clear.

What this case is testing

Efficient use of the investigation results already available.
Focused assessment of fatigue, menstrual change and associated symptoms.
Consideration of relevant alternative explanations for fatigue.
Exploration of functional impact, anxiety, carer strain and financial pressure.
Clear explanation of the thyroid results and treatment rationale.
Addressing concerns about medication dependency, duration and cost.
Shared planning for monitoring, follow-up and safety-netting.

Patient priorities and concerns

Sarah wants an explanation for her symptoms and wants to know whether treatment can help. She wants clear information about whether medication is needed, how long it may be needed and what monitoring involves. She is concerned that levothyroxine might be addictive, worries about lifelong tablets and cost, and wants a plan that fits around work, parenting and caring responsibilities.

Central challenge

The clinician needs to explain the diagnosis and treatment clearly while recognising Sarah’s concerns and the strain her symptoms are placing on her daily life. A result-focused consultation that does not address her practical and emotional concerns may leave her worried or disengaged.

Common GP trainee pitfalls

Focusing on the thyroid results without exploring how Sarah is coping day to day.
Dismissing the symptoms as stress or overlooking her worries about medication and cost.
Failing to ask about the impact and severity of her heavier periods.
Repeating investigations or history already available instead of using the results efficiently.
Giving a generic follow-up plan that does not take account of her work and caring responsibilities.
Leaving Sarah unclear about treatment, monitoring, costs or when to seek review.

What good looks like

The trainee listens to Sarah’s account, acknowledges the impact of her symptoms, explains the significance of the results using the numbers, addresses her concerns about treatment and cost, and agrees clear monitoring and follow-up. They check what Sarah has understood and invite further questions.

Learner checkpoint

Have I explained what the results mean while also addressing what matters most to Sarah about treatment and its practical impact?

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📝 Section 2: Patient-Centred Consultation and Data Gathering

Start with an open question

Begin by inviting Sarah to describe what has been happening, for example: “Could you tell me in your own words what has been going on and what you were hoping we could sort out today?”

Time-efficient data gathering

Use the history and results already available to guide focused questions. Clarify the progression and impact of the fatigue, the menstrual changes and associated symptoms. Screen for the listed concerning symptoms, explore relevant alternative explanations, and ask about Sarah’s priorities before moving to an explanation and plan.

High-yield questions

Fatigue and function: How long has the fatigue been present? Is it changing? Does rest help? How is it affecting work, home life, parenting, caring and dog walking?
Associated symptoms: Ask about feeling cold, weight change, constipation, skin and hair changes, hand tingling or numbness, appetite and mood.
Menstrual change: Clarify the change in duration and heaviness, clots and the effect on Sarah. Ask about the concerning symptoms identified in the case, including dizziness, syncope, breathlessness, chest pain and palpitations.
Relevant context: Ask about coeliac symptoms and diet, current medication, family history and the demands of caring for her mother.
Patient perspective: Explore what Sarah thinks may be causing the symptoms, what worries her about the results and what she hopes treatment will achieve.

Functional, psychosocial or contextual assessment

Ask how fatigue and heavier periods affect Sarah’s job, parenting, housework, walking the dogs and caring for her mother. Acknowledge her anxiety, financial worries and the cost of gluten-free food. If she becomes tearful, pause and respond to the emotion rather than moving straight to advice.

Explore ideas, concerns and expectations

Sarah may wonder whether the symptoms relate to coeliac disease, poor absorption, hormones or stress. She is worried about medication dependency, long-term treatment and cost. She wants an explanation, information about treatment and monitoring, and practical reassurance about managing health alongside her responsibilities.

Recognise and respond to cues

Notice signs of exhaustion, anxiety, feeling overwhelmed and tearfulness. If Sarah becomes tearful when discussing her mother or how she is coping, acknowledge the pressure she is under and give her time to respond. Avoid dismissing the symptoms as “just stress”.

Useful consultation phrases

“It sounds as though you’ve been trying to keep everything going while feeling really unwell yourself.”
“You mentioned that your periods have changed. Could I ask a little more about that and how it is affecting you?”
“What were you most concerned these results might mean?”
“Would it help if I explained what each of the thyroid numbers means?”
“What questions do you have about taking the medication or the monitoring?”

Consultation flow and signposting

Invite Sarah’s account and agree the main priorities for the appointment.
Clarify the fatigue, associated symptoms and menstrual changes.
Ask about the concerning symptoms identified in the case and the effect on daily functioning.
Explore relevant medical, family and social context, including coeliac disease, medication, caring responsibilities and cost concerns.
Explain the thyroid results and connect them with Sarah’s symptoms.
Discuss treatment, monitoring and practical considerations, addressing questions and preferences.
Summarise the agreed plan, check understanding and explain when and how Sarah should seek review.

Summarising and checking understanding

A useful summary could be: “You’ve described increasing tiredness, feeling cold, constipation, skin and hair changes, weight gain and heavier periods. Your thyroid results show a high TSH and a low Free T4, which fits with an underactive thyroid.” Then check whether Sarah would like any part of the explanation repeated or clarified.

Data gathering self-check

Before moving to management, check that you understand:

The timeline, severity and impact of Sarah’s fatigue.
The menstrual changes and relevant concerning symptoms.
Associated symptoms and relevant negatives provided in the case.
Her coeliac history, medication and family history.
Her mood, caring responsibilities, financial concerns and treatment preferences.
What she understands and worries about regarding the results.

Assessment domain mapping

Data gathering

Integrate the available blood results and relevant history.
Assess symptoms, risk features and functional impact.
Explore psychosocial context and alternative explanations for fatigue.

Clinical management

Explain the findings and discuss treatment, monitoring and follow-up.
Agree practical next steps and safety-netting.

Relating to others

Acknowledge Sarah’s concerns, explain clearly, invite questions and check understanding.

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📝 Section 3: Clinical Reasoning and Personalised Management

Prioritised clinical reasoning

The case identifies overt primary hypothyroidism. The combination of TSH 32.7 mU/L, Free T4 6.4 pmol/L and Sarah’s symptoms supports that working diagnosis. The case also asks the clinician to consider other explanations for fatigue, including iron deficiency, B12 deficiency, diabetes, early menopause, anxiety or depression, coeliac relapse and chronic illness, using the history and supplied results where available.

Relevant results to put in context include haemoglobin 134 g/L, ferritin 54 μg/L, negative tTG IgA, FSH 5.3 IU/L and random glucose 4.9 mmol/L. These results should be explained accurately and should not be used to claim that every possible alternative cause has been excluded.

Clinical reasoning script

“Your TSH is 32.7, which is above the usual range of 0.4–4.0, and your Free T4 is 6.4, below the usual range of 10–22. Together, those results show that your thyroid is underactive. That fits with several of the symptoms you have described, including tiredness, feeling cold, constipation, weight gain and changes to your skin and hair.”

Decision points

How should the thyroid results and symptoms be explained to Sarah?
What treatment and monitoring plan is appropriate to discuss?
What further review is needed if the hand symptoms or heavy periods persist?
How can the follow-up plan be made practical around Sarah’s work and caring responsibilities?
What information does Sarah need to make an informed decision about treatment?

Management priority

Explain the diagnosis and treatment rationale, address Sarah’s concerns about medication and cost, and agree a clear plan for treatment, monitoring, review and safety-netting.

Management options

Discuss levothyroxine as thyroid hormone replacement and individualise the dose.
Explain the monitoring plan described in the case: repeat TSH and T4 every 6–8 weeks until stable, then annually.
Review symptoms and possible side effects alongside blood-test results.
Review cholesterol and cardiovascular risk if relevant.
Consider other causes, including B12 deficiency, if tingling persists or remains unexplained.
Reassess heavy periods if they persist despite thyroid treatment or are clinically concerning.
Discuss lifestyle measures as tolerated, including gentle activity without pushing beyond what Sarah can manage while symptomatic.
Offer verbal and, if useful, printed or reputable online information.

Personalised plan

Take account of Sarah’s part-time work, parenting, caring for her mother, anxiety and financial concerns. Explain monitoring in clear, practical terms and agree follow-up arrangements that are workable for her. Ask what support she has with caring responsibilities and whether information in writing would help.

Shared decision-making

Invite Sarah’s questions about whether treatment is needed, how long it may continue, whether it is addictive, how quickly she may feel better and how often blood tests are needed. Explain that levothyroxine replaces a hormone her body is not making enough of. Discuss cost concerns directly and check that the proposed plan feels manageable to her.

Safety-netting

Explain how Sarah can seek review if symptoms worsen, if severe fatigue becomes disabling, if new concerning symptoms develop, or if symptoms do not improve despite treatment and appropriate monitoring. Advise review if she develops palpitations, sweats or chest pain, or if heavy bleeding worsens or is associated with dizziness, breathlessness, fainting or inability to function. Make clear who to contact and when.

Follow-up and coordination with other professionals

Arrange repeat thyroid blood tests every 6–8 weeks until stable and review symptoms and side effects alongside the results. Once stable, the case describes annual monitoring. Consider follow-up arrangements that fit around Sarah’s work and caring responsibilities. Consider support or signposting relating to carer strain, prescription costs, coeliac disease and thyroid information where appropriate.

Learner checkpoint

Can Sarah explain what the results mean, why treatment is being discussed, when she will be reviewed and what she should do if symptoms worsen?

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📝 Section 4: Key Guidance, Resources and References

Relevant guidance areas

NICE CKS: Hypothyroidism.
BNF: Levothyroxine.
NHS Help with Health Costs.
RCGP SCA Toolkit.
Thyroid UK.
Coeliac UK.

Key principles to remember

Use the supplied results and symptoms together to explain the clinical picture.
Address concerns about medication dependency, likely duration, monitoring and cost directly.
Make the plan understandable and practical for the patient.
Explore the effect of symptoms and caring responsibilities on daily life.
End with clear next steps, follow-up and safety-netting.

Transferable learning for future cases

When discussing abnormal results, combine clear explanation of the numbers with exploration of the patient’s concerns, understanding and circumstances. A clinically coherent plan is more useful when the patient understands the reasoning and can realistically manage the follow-up.

Supervisor or examiner lens

The assessment focuses on how well the trainee integrates the results, explores symptoms and context, explains the diagnosis, responds to concerns about medication and cost, and agrees a clear, personalised plan with appropriate monitoring and safety-netting.

Final learner takeaway

Explain the results in a way that makes sense to the patient, then build a practical plan around the person’s life as well as the diagnosis.

Missing or conflicting information

No booking note was supplied; the booking note above was created using only the stated reason for attendance and presenting information.
No letter was supplied.
No image information was supplied.
Pregnancy status is not provided.
B12 and folate results are not provided.
The presence or absence of all features relevant to severe hypothyroid complications and menorrhagia is not provided.
The source says all other tested parameters were within normal limits but does not list every parameter tested.
No confirmed safeguarding concern or safeguarding outcome is provided.
The patient address was supplied in the case; no fictional address was created.
Field 55 was not defined in the supplied requirements.

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Start the quiz

Thyroid disease

Case overview

Opening statement

Information freely divulged

Information given on questioning

Behaviour

📝 Section 1: Case Overview and Consultation Priorities

📝 Section 2: Patient-Centred Consultation and Data Gathering

📝 Section 3: Clinical Reasoning and Personalised Management

📝 Section 4: Key Guidance, Resources and References

Authoring credit: