History Taking · Intermediate · Endocrinology

Fatigue and Weight Gain in a 52-Year-Old Woman

Practise this PLAB 2 history taking station on Hypothyroidism. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Alice Crawford, a 52-year-old woman, has come to see you with complaints of persistent fatigue, weight gain, and feeling unusually cold. She has noticed these changes over the past six months. Please take a focused history and discuss your initial management plan with the patient.

Background notes: PMH: Nil significant. Appendectomy age 16. PMHx peri-menopausal changes

What this station tests

  • Identifying the hypothyroid symptom cluster: fatigue with hypersomnia, weight gain, cold intolerance, cognitive slowing, constipation, dry skin, hair thinning
  • Distinguishing hypothyroidism from depression: hypersomnia not insomnia, cold not hot, no primary anhedonia, frustration rather than primary low mood
  • Distinguishing from perimenopause: cold intolerance (not hot flushes), constipation, and cognitive changes go beyond menopausal symptoms
  • Appropriate investigation panel: TFTs, thyroid antibodies, FBC, lipids, and coeliac screen (associated autoimmune conditions)
  • Providing hope: 'most people feel significantly better within 4 to 6 weeks' is accurate and motivating

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Hypothyroidism stations test whether candidates can identify the slow-onset symptom cluster that patients often attribute to ageing, depression, or menopause. The candidate must connect fatigue, weight gain, cold intolerance, and cognitive slowing into a single diagnosis. Mrs Crawford is 52, presenting with 6 months of fatigue, weight gain, and feeling cold. She thinks she might be depressed or 'just getting old.' Open with: 'Mrs Crawford, these symptoms have been building for a while. Tell me about all the changes you have noticed.' The word 'all' encourages a comprehensive account.

Core approach

The symptom cluster is classic hypothyroidism. Fatigue: exhausted despite 10 hours of sleep, wakes unrefreshed, afternoon energy crash, cannot concentrate at work. Weight gain: approximately 7kg without dietary change. Cold intolerance: wearing extra layers, turning up heating when others are comfortable. Cognitive slowing: difficulty concentrating, memory lapses, feeling 'foggy.' Constipation. Dry skin. Hair thinning. Voice slightly deeper. Reduced libido. These features together are strongly suggestive.

Distinguish from depression and perimenopause, which she suspects. Depression: she feels slightly down but says it is mainly frustration with the fatigue, not primary low mood. No anhedonia, no suicidal ideation, sleep is excessive not reduced (hypersomnia). Perimenopause: she is 52 and peri-menopausal, but hot flushes would be expected (she is cold, not hot), and menopause does not explain constipation, dry skin, and cognitive slowing.

Family history: check for autoimmune thyroid disease. PMH: appendicectomy, peri-menopausal changes. No medications (no lithium, amiodarone, which can cause hypothyroidism). No previous thyroid surgery or radioiodine treatment.

Closing and safety netting

Explain the likely diagnosis: 'Mrs Crawford, the combination of fatigue despite long sleep, weight gain, feeling cold, and the changes in your skin and concentration strongly suggests an underactive thyroid. This is very common and very treatable.' Arrange TFTs (TSH and free T4), FBC (anaemia also causes fatigue), and thyroid antibodies (anti-TPO for Hashimoto's). Check lipids (hypothyroidism causes dyslipidaemia) and coeliac screen (associated with autoimmune thyroid disease).

If confirmed: levothyroxine, starting low and titrating to normalise TSH. 'Most people feel significantly better within 4 to 6 weeks of starting treatment.' Address her depression concern: 'If this is your thyroid, treating it should improve your energy, mood, and concentration. We do not need to think about antidepressants until we know.'

Safety net: 'If you develop chest pain, severe breathlessness, or confusion while we are waiting for results, come in urgently.' Arrange follow-up in 1 week for results.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for hypothyroidism. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Complete hypothyroid symptom assessment. Depression and menopause actively distinguished. Family history of autoimmune disease checked. Medication review for thyroid-affecting drugs. All symptoms connected into single diagnosis.

Costs marks: Not identifying the hypothyroid cluster. Accepting depression or menopause without investigation. Not checking medications.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: TFTs with thyroid antibodies arranged. Associated investigations (FBC, lipids, coeliac). Levothyroxine management explained. Follow-up plan. Correct not to start antidepressants before thyroid results.

Costs marks: Prescribing antidepressants before thyroid check. Incomplete investigation panel. No follow-up plan.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Validating that symptoms are real and not 'just ageing.' Providing hope about treatment response. Deferring depression treatment until thyroid is checked (not dismissing it). Acknowledging impact on work and family.

Costs marks: Dismissing symptoms as ageing. Being vague about treatment prospects. Not acknowledging functional impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Diagnosing depression without checking thyroid function. Hypothyroidism is one of the most commonly missed causes of fatigue and low mood. Candidates who prescribe antidepressants or refer for CBT without checking TFTs miss a treatable medical cause.
  2. Attributing symptoms to menopause. She is 52 and peri-menopausal, but menopause causes hot flushes (not cold intolerance), does not explain constipation or dry skin, and does not cause hypersomnia. Candidates who accept the menopause explanation without investigation miss the diagnosis.
  3. Not checking for associated autoimmune conditions. Coeliac disease is associated with autoimmune thyroid disease. A coeliac screen should be included in the investigation panel. This is commonly overlooked.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a hypothyroidism history in PLAB 2?

Hypothyroidism stations test whether candidates can identify the slow-onset symptom cluster that patients often attribute to ageing, depression, or menopause. The candidate must connect fatigue, weight gain, cold intolerance, and cognitive slowing into a single diagnosis. Mrs Crawford is 52, presenting with 6 months of fatigue, weight gain, and feeling cold.

Where are marks won and lost in this hypothyroidism station?

Examiners reward: Complete hypothyroid symptom assessment. Depression and menopause actively distinguished. Family history of autoimmune disease checked. Medication review for thyroid-affecting drugs. Candidates are penalised for: Not identifying the hypothyroid cluster. Accepting depression or menopause without investigation. Not checking medications.

Where do candidates most often go wrong in this station?

Diagnosing depression without checking thyroid function. Hypothyroidism is one of the most commonly missed causes of fatigue and low mood. Candidates who prescribe antidepressants or refer for CBT without checking TFTs miss a treatable medical cause.

Can I do well in this station without real-world experience of hypothyroidism?

This station rewards process over personal experience. The skill being assessed: Distinguishing hypothyroidism from depression: hypersomnia not insomnia, cold not hot, no primary anhedonia, frustration rather than primary low mood. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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