Student Instructions
You are a junior doctor working in general practice.
Miss Evergreen has come to see you today because she has been feeling ‘just not with it’ recently. She has told the nurse that she just can’t seem to find the energy anymore to go about her daily tasks and wants to find out if there is a medical cause for this.
Please take a history from Miss Evergreen and formulate a differential diagnosis.
After 7 minutes, the examiner will stop you to ask you a few questions.
Patient Instructions
Name: Miss Rosie Evergreen
Age: 34 years old
Job: Personal Assistant (PA)
PC
Within the last two months you have been feeling very tired and lacking in energy. You also notice that you have been putting on a lot of weight very quickly without any increase in your appetite or diet. The amount of weight gained is roughly 10kg during the last month. You feel that your face is now very round, and your waistline has increased so much that you are starting to see stretchmarks across your tummy.
You have also noticed that your skin is quite spotty and embarrassingly you think you have now developed an increase in the amount of your facial hair. Your periods are not irregular and appear to be normal. You do not notice any neurology or visual disturbances. You are rather depressed by all of this and feel very unattractive and ugly as a result.
PMH
Asthma- but not on steroids
T2DM- only diagnosed recently, within last month by GP
DH
NKDA
Salbutamol inhalers
Ipratropium bromide inhalers
Metformin 500mg po od
You do not take any steroids
SH
You do not drink alcohol or smoke.
You attend aerobics classes twice a week for an hour and have also been going to the gym 3 times a week on top of this recently to try to lose weight, but it hasn’t helped.
You are sleeping well at night and can’t understand why you are so tired. You are not going through a stressful time at work and everything is otherwise going well in your life.
ICE
You just want to get back to normal life and feel very upset by all this. You are not in a relationship and desperately want to get married soon and start a family but cannot see how any man would want to date you looking the way you do!
Questions
What is the likely diagnosis?
Cushing’s syndrome
What are your differentials?
Hypothyroidism
Poorly controlled diabetes
Chronic alcohol consumption
What investigations would you do?
Routine blood tests: FBC, U&E, LFTs, fasting glucose, HbA1c levels
Blood tests for pituitary function such as thyroid hormones, prolactin, FSH, LH etc
24-hour urinary cortisol levels
Low dose dexamethasone suppression tests
Midnight cortisol levels to look for loss of diurnal cortisol variation
MRI of the pituitary gland
Referral to endocrinologist for treatment