History Taking · Intermediate · Endocrinology

Weight Loss and Palpitations in a 38-Year-Old Woman

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Ms Yvonne Newton, a 38-year-old woman, has come to see you with weight loss, palpitations, tremor, and heat intolerance that have developed over the past two to three months. She is concerned about her symptoms and worried about what might be causing them. Please take a focused history exploring these symptoms and discuss the possibility of thyroid dysfunction.

Background notes: PMH: Asthma (mild, infrequent), Migraine with aura (controlled on topiramate)

What this station tests

  • Pattern recognition: connecting weight loss with increased appetite, palpitations, tremor, heat intolerance, and menstrual changes into a single thyroid diagnosis
  • Distinguishing hyperthyroidism from anxiety: weight loss with increased appetite and heat intolerance are the discriminating features
  • Screening for Graves-specific features: ophthalmopathy, goitre, pretibial myxoedema
  • Appropriate initial management: beta-blocker for symptom relief, not carbimazole before confirmed diagnosis
  • Thyroid storm safety netting: tachycardia, fever, confusion, agitation as red flags requiring emergency attendance

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

Hyperthyroidism stations test pattern recognition: the candidate must connect weight loss, palpitations, tremor, and heat intolerance into a single endocrine diagnosis rather than investigating each symptom separately. Ms Newton is 38, presenting with 2 to 3 months of weight loss (8 to 10kg despite increased appetite), palpitations, tremor, heat intolerance, and insomnia. Open with: 'Ms Newton, you have several symptoms that have developed together. Tell me about them and how they are affecting you.'

Core approach

The symptom cluster is classic hyperthyroidism. Weight loss despite increased appetite (the paradox that is almost pathognomonic). Palpitations at rest and with activity, sometimes irregular (possible AF). Fine tremor in hands. Heat intolerance (wearing fewer layers than others, cannot tolerate warm rooms). Insomnia and anxiety. Increased bowel frequency. Menstrual changes (lighter, less frequent periods). Each symptom alone has multiple differentials, but together they point to a single diagnosis.

Distinguish from anxiety (which she and her GP may have initially considered). Anxiety can cause palpitations, tremor, and insomnia, but does not cause weight loss with increased appetite, heat intolerance, or menstrual changes. Ask specifically about these discriminating features.

Screen for Graves-specific features. Eye symptoms: any grittiness, dryness, prominence, double vision, or lid retraction? (Graves ophthalmopathy occurs in approximately 25% of Graves patients). Neck swelling: has she noticed her neck getting thicker? (diffuse goitre). Skin changes: pretibial myxoedema (rare but specific). These features distinguish Graves from other causes of hyperthyroidism.

Check her medications: she takes topiramate for migraine with aura. Topiramate does not cause hyperthyroidism, but its weight loss side effect may have initially masked the hyperthyroid weight loss. ICE: she worries about cancer (weight loss), her heart (palpitations), or anxiety.

Closing and safety netting

Explain the likely diagnosis: 'Ms Newton, the combination of weight loss with increased appetite, palpitations, tremor, heat intolerance, and your menstrual changes all point toward an overactive thyroid. This is a treatable condition.' Arrange urgent thyroid function tests (TSH, free T4, free T3). If confirmed, TSH receptor antibodies will distinguish Graves from other causes.

If symptomatic while waiting for results, consider starting a beta-blocker (propranolol) for palpitations and tremor relief. Not carbimazole yet (needs confirmed diagnosis first and specialist input). Referral to endocrinology. Address her cancer fear: 'Weight loss with increased appetite is very different from cancer-related weight loss, where appetite is reduced.'

Safety net: 'If your heart rate becomes very fast, you develop chest pain, confusion, high fever, or severe agitation, go to A&E as this could indicate thyroid storm, a rare but serious complication.' Follow-up after blood results.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for graves' disease. 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: Symptom cluster identified as endocrine. Discriminating features from anxiety established (weight loss with appetite, heat intolerance). Graves-specific features screened (eyes, goitre). Menstrual history taken. Medication review.

Costs marks: Treating symptoms individually. Not distinguishing from anxiety. Not screening for eye disease. Not checking menstrual history.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Urgent TFTs arranged. Beta-blocker for interim relief. Endocrinology referral. Not starting carbimazole prematurely. Thyroid storm safety netting.

Costs marks: Starting carbimazole before diagnosis. No TFTs. No referral. No thyroid storm warning.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer fear (weight loss with increased appetite is different from cancer). Reassuring about treatability. Explaining that symptoms should improve with treatment.

Costs marks: Not addressing cancer concern. Being vague about diagnosis. Not reassuring about treatability.

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. Attributing the symptoms to anxiety without checking thyroid function. Many hyperthyroid patients are initially diagnosed with anxiety disorder. The weight loss with increased appetite and heat intolerance are the clues that this is endocrine, not psychiatric.
  2. Starting carbimazole before confirming the diagnosis. Carbimazole has significant side effects (agranulocytosis) and should not be started without confirmed TFTs and ideally specialist input. Beta-blocker is appropriate for interim symptom relief.
  3. Not asking about eye symptoms. Graves ophthalmopathy occurs in approximately 25% of patients and can be sight-threatening. Candidates who diagnose hyperthyroidism without screening for eye involvement miss a clinically important finding.

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

How should I structure the graves' disease history in this PLAB 2 station?

Hyperthyroidism stations test pattern recognition: the candidate must connect weight loss, palpitations, tremor, and heat intolerance into a single endocrine diagnosis rather than investigating each symptom separately. Ms Newton is 38, presenting with 2 to 3 months of weight loss (8 to 10kg despite increased appetite), palpitations, tremor, heat intolerance, and insomnia.

What are examiners marking in this graves' disease station?

Marks are won for: Symptom cluster identified as endocrine. Discriminating features from anxiety established (weight loss with appetite, heat intolerance). Graves-specific features screened (eyes, goitre). Marks are lost for: Treating symptoms individually. Not distinguishing from anxiety. Not screening for eye disease. Not checking menstrual history.

What is the most common mistake candidates make in this graves' disease station?

Attributing the symptoms to anxiety without checking thyroid function. Many hyperthyroid patients are initially diagnosed with anxiety disorder. The weight loss with increased appetite and heat intolerance are the clues that this is endocrine, not psychiatric.

How do I prepare for this station if I have not managed graves' disease in clinical practice?

Structure beats experience here. Focus on distinguishing hyperthyroidism from anxiety: weight loss with increased appetite and heat intolerance are the discriminating features. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

Related cases