Presenting complaint:

65 year old female presented with tiredness for the past 6 months

History of presenting illness:

I have been feeling lethargic for the past 6 months. I used to be quite energetic and was able
to play with my grandchildren, but I am just tired all the time now and not as energetic as
before. It is progressively worse in these 6 months. I sleep about 8 hours a day and sleeping
more does not make any difference.
I have also been feeling more breathless in the past 3 months. It only happens when I exert
myself, especially when I am doing housework. It is relieved by rest.
I also noticed numbness in both my feet for the past month. It feels as if the sensation is not
as strong as before. I think it could be due to me not exercising. My daughter also told me a
few weeks ago that my gait looks slightly abnormal. I am not sure what she meant by that.
I think I look slightly pale as well.

No chest pain, nausea, vomiting, gum/GI bleed, polydipsia, polyuria, sweating

Past medical history:

No diabetes, hypertension, hypercholesterolemia
I had my stomach and part of my small intestines removed 7 years ago. 7 years ago, I was
vomiting continuously for 3 days, so my family brought me to the hospital. The doctor
ordered some scans and found that there was a blockage in my stomach that’s why food
couldn’t enter my stomach. It was probably because of my gastric problem which I have had
since 10 years ago.
Menopause at age 50
Drug history:
Not on any medication at the moment. NKDA

Family history:
Married with one daughter. She is healthy. My husband passed away in a car accident 6
years ago. No other significant family history

Social history:
I do not smoke nor consume alcohol. I have been a strict vegetarian since my husband
passed away. I don’t usually consume dairy products and milk as well. I’ve been adviced by
my nutritionist to take supplements but I always forget to take them.
I am not working. I am currently living with my daughter and her family, taking care of my
grandchildren.

Ddx: Vitamin B12 deficiency

Vitamin B12 Deficiency

Appropriate introduction (1) full name and role, (1) checks patient’s name - 2 1 0
Explains purpose of interview and gains consent (2=does well, 1=adequately, - 2 1 0
0=poorly or not done)
Starts with an open question and listens without interrupting (1=both) - 2 1 0
Presenting complaint:
Duration and progression of tiredness (1), compare it to 6 months ago (1), sleep 3 2 1 0
pattern (1)
Ass. Symptoms (anaemia): breathlessness (1) and its progression (1) relieving 5 4 3 1
(1) and aggravating factors (1) exercise tolerance (1) 2 0
Anaemia: paresthesia, ataxic gait (1), dizziness, dimness of vision, pallor (1), 3 2 1 0
bleeding (GI or gums) (1)
TRO hypothyroidism: swelling in the neck, weight gain, cold intolerance, - - 1 0
constipation, menorrhagia (1=two symptoms, 0=one/ none)
TRO DM: polydipsia, polyuria, frothy urine, chest pain, vision problems (1=any - - 1 0
two, 0=one or none)
TRO depression: mood (1) - - 1 0
TRO cushing’s: weight gain, striae, hirsutism, buffalo hump, muscle weakness, - - 1 0
skin hyperpigmentation (1=any two, 0=one/ none)
Systemic review: Fever, headache, weight loss/gain, joint pain, skin changes, - 2 1 0
cough, appetite (2=any three, 1=two, 0=one/none)
Menstruation/ menopause (1) - - 1 0
Past medical history:
Previous occurrence (1), surgical history (1) frequent infections, radiotherapy – 3 2 1 0
TRO leukaemia (1)
Hypertension, hypercholesterolemia, DM (1=two, 0=one/none), bleeding - 2 1 0
disorder, others (1)
Drug history:
Prescribed/ over the counter medications (1), drug allergies (1), anticoagulants/ 3 2 1 0
anti-platelets – bleeding (1)
Family history:
DM, HTN, hypercholesterolemia (1), bleeding disorders (1), thyroid problems, 3 2 1 0
malignancy (leukaemia esp.) (1)
Social history:
Smoking, alcohol, illicit drugs (2) - 2 1 0
Diet, ask specifically about change in diet or vegetarian (2) supplements (1) 3 2 1 0
Occupation, stress (1), daily activities and effect on life (1) - 2 1 0
Others:
Summarizes history to patient (1), thanks patients and explains next step (1) - 2 1 0
Appropriate question style (mix of open and closed questions) (2=does well, - 2 1 0
1=adequately, 0=poorly/not done)
Elicits patient’s ideas (1), concerns (1), expectations (1) 3 2 1 0

Ddx (1): / 50
65 year old female came in to the clinic complaining of tiredness

for the past 6 months. Please take a complete history from her

and formulate a differential diagnosis. You have 7 minutes to

complete the task.