1. Time Efficient Data Gathering

1. Be Efficient and Fluent: While it is important to gather the story and symptoms, aim for a smooth and purposeful approach. Avoid making the consultation feel like a clerking exercise—focus on what is most relevant at each stage.
2. Cover Key Symptoms: Make sure you ask specifically about all relevant symptoms, including any that could have diagnostic significance, such as eye symptoms in hyperthyroidism.
3. Clarify Results: When discussing test results, be specific. Don’t just say “most are normal”; mention which ones have been checked and their outcomes, to provide clarity and reassurance.
4. Explore Patient’s Perspective: Ask questions to fully understand the patient’s ideas, concerns, and expectations regarding their symptoms and diagnosis. Dig deeper into their understanding of the potential condition.
5. Summarise Clearly: Use summaries, but do so smoothly and as part of a natural conversation rather than a checklist.

References:
NICE NG145, recommendations 1.2.3–1.2.8 (Assessment)

2. Clinical Management & Medical Complexity

1. Actively Plan Management: In follow-up cases where the diagnosis is already known, focus prominently on the management options and safety. Be prepared to discuss initiating treatment if the patient is symptomatic (e.g., consider starting carbimazole) and clearly explain your reasoning.
2. Explain Treatments Properly: When you mention medication (e.g., carbimazole, beta blockers), briefly explain what these are, their purpose, and possible side effects or monitoring needs.
3. Discuss Safety Netting: Discuss what symptoms to look out for (e.g., eye symptoms, infection due to carbimazole), what to do if they develop, and clear follow-up plans (e.g., blood tests, ultrasound, checking thyroid antibodies).
4. Be Proactive: Where appropriate, mention how you’d manage delays or waiting times for specialist input (for example, by seeking immediate advice from an endocrinologist or via Advice & Guidance).
5. Consider the Future: Briefly outline possible future steps, such as what happens if initial treatments don’t work (e.g., possibility of surgery or radioactive iodine treatment).

3. Relating to Others

1. Show Empathy: Respond to significant patient concerns or emotional moments (e.g., bereavement, family worries). Frame health positively. It does look like you have a problem with your thyroid, the good news is there is very effective treatment available.
2. Avoid Jargon: Use plain language, and if you must use terms like “autoimmune” or “beta blocker,” always explain them in simple terms.
3. Share Decisions: Involve the patient in management planning and check their understanding regularly. Ask for their preferences and concerns at key decision points.
4. Be Specific About Risks/Next Steps: Don’t be vague; spell out what will happen next, what to watch for, and how the patient will be supported along the way.

4. Differential

NICE guidance on differentials includes:

1. Graves’ disease (most common, especially in women <50, often with eye signs)
2. Toxic multinodular goitre
3. Toxic adenoma
4. Subacute (de Quervain’s) thyroiditis
5. Drug-induced (amiodarone, lithium)
6. Ectopic (rare)
7. Thyroid malignancy (rare)

5. Impact

• Specifically ask about the effect on mental health and day-to-day function. NICE stresses a holistic approach.
• “How are these symptoms affecting your work, family or mood?”

6. Options

NICE NG145 recommends:

1. Referral to endocrinology (urgently if severe symptoms, eye involvement, or suspected pregnancy)
2. Symptom control: Start a beta blocker (propranolol preferred, unless contraindicated)
3. Antithyroid drugs (e.g. carbimazole): Can be initiated in primary care under specialist guidance, hospital out patient clinc waits may be too long.
4. Arrange thyroid antibody testing if available, to help clarify etiology (especially if Graves' suspected)
5. Arrange thyroid ultrasound if there is a thyroid nodule or concern about malignancy
6. Further bloods: Repeat TFTs within a few weeks to monitor, plus baseline FBC/LFTs if starting carbimazole
7. Safety net for complications: e.g., thyroid crisis, cardiac arrhythmia, worsening mental state, eye symptoms
8. Provide written information and signpost support resources (British Thyroid Foundation, NHS/NICE)

7. Understanding

• Check Claire’s understanding at each stage: “What questions do you have?”
• Confirm she feels supported and has a plan.

Further Reading:

• NICE NG145: Thyroid disease: assessment and management
• NICE CKS: Hyperthyroidism
• BNF, Carbimazole safety

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