GPSN Monash GP Revision Day 2019

CANDIDATE INSTRUCTIONS

Station No: 1
Station title: Hannah Harp
Time allowed: 8 minutes

You are working as a junior doctor in General Practice.

Hannah Harp is a 23-year-old woman with Down syndrome who is known to the clinic. Her
mother Marianne has come to see you as she is concerned about Hannah’s behaviour
recently.

Hannah is at work today and is not present in the consultation. Marianne has been
appointed as Hannah’s medical decision maker. You are permitted to speak to Marianne
about Hannah.

Past medical history: Down syndrome, previous atrioventricular septal defect (AVSD)
repaired at birth.

Current medications: Movicol® (macrogol with electrolytes) 1 sachet as required.

No other prescribed, over-the-counter or complementary medicines.
No allergies or drug intolerances.

Family history: Nil relevant.

Social history: Lives with mother Marianne, father Peter and brother Nathan. Non-smoker
and non-drinker. Works as a gardener at the local sporting club.

TASKS:
1. Take a focussed history from Hannah’s mother Marianne (3 minutes).
2. Taking into account likely differential diagnoses, outline what investigations would be
IMPORTANT to request AND explain your rationale for ordering each – the examiner
will provide results as appropriate, which you should then interpret (1.5 minutes).
3. Formulate and explain a management plan to Marianne (3.5 minutes).

IMPORTANT NOTES:
● You are not required to perform an examination.
● You will not be prompted to move to the next task.

1
GPSN Monash GP Revision Day 2019

SIMULATED PATIENT INSTRUCTIONS

Station No: 1
Station title: Hannah Harp
Time allowed: 8 minutes

Gender: Female
Age: 55

You are the mother of Hannah Harp, a 23-year-old woman with Down syndrome. You have
come to see the GP today because you are concerned about a recent change in Hannah’s
behaviour.

How to start the station:

“Thanks for seeing me today. I’m a bit worried about Hannah. She has been acting strangely
lately. I was hoping that you might be able to work out what is wrong.”

Clinical details (please provide as asked by the candidate):

HOPC
● Premorbid behaviour: Hannah is normally happy and outgoing. She enjoys going to
work and seeing her friends.
● Behaviour change: Over the past month Hannah has become quieter and more
withdrawn. She spends more time in bed and has missed several days of work
because she has refused to get up. There was apparent no trigger.
● Beliefs/concerns: Unsure, but you are worried about her.
● Expectations: You hope that the doctor can work out why Hannah is acting so
strangely.

Systems review
● Endocrine: Over the past 2 months, Hannah has been more constipated than usual
and required an extra 1—2 sachets of Movicol® (macrogol with electrolytes) each day.
She has also gained 4kg which you attribute to decreased level of activity. She has
been wearing her coat and scarf more often than usual, including inside the house
when it is not very cold. NO swelling on the front of her neck or changes to periods,
hearing, skin or hair.
● Haematological: NO fevers, night sweats, recurrent infections, bone pain, easy
bruising/bleeding or pallor.
● Gastrointestinal: Loss of appetite and constipation as above. NO tummy pain,
vomiting, diarrhoea or bleeding from the back passage.
● Cardiovascular: NO chest pain or shortness of breath.
● Rheumatological: NO sore joints, sore muscles or rash.
2
GPSN Monash GP Revision Day 2019

● Psychiatric: Possible low mood and loss of enjoyment in some of her normal activities
as evidenced by behaviour change but not stated by Hannah herself. NO changes in
sleep, suicidal throughts, self-harm or strange beliefs. NOT seeing or hearing things
that are not there.

Psychosocial review
● Hannah has worked at her current job as a gardener for the past three years. She
works 9am to 3pm, Monday to Friday. She works with two other employees who have
mild intellectual disabilities. They all get along well and socialise outside of work.
Hannah’s friends are also worried about her.
● Hannah is not currently in a relationship and is not sexually active as far as Marianne
knows.
● There have been no recent changes in home or work circumstances, nor any deaths
or fallings out with family or friends.

Down syndrome management

● Hannah sees her GP once per year for the following tests: measurement of height and
weight, measurement of blood pressure and blood tests to check her blood count
and to evaluate her thyroid function. The most recent visit was nine months ago and
all results were within normal limits.
● She sees a cardiologist once per year and has had no heart issues since the hole in
her heart (AVSD) was repaired at birth.
● She has her hearing tested by an audiologist once per year and sees an optometrist
once every two years. She is short-sighted and wears glasses.

3
GPSN Monash GP Revision Day 2019

INVESTIGATION RESULTS

Please provide this sheet to the candidate once all investigations with rationale have been
ordered.

ECG

Sinus rhythm. Heart rate 55bpm.

Full blood examination

Parameter Result Normal range

Haemoglobin 131 110—160g/L
White cell count 8.2 4.0—11.0 x 109/L
Platelets 190 150—450 x 109/L

Remainder of the full blood examination is normal

Thyroid function tests

Parameter Result Normal range

Thyroid stimulating hormone 24.3 0.4—4.8mIU/L
Free T4 6.6 8.0—16.0pmol/L

Thyroid antibodies

Parameter Result Normal range

Anti-thyroglobulin antibodies 9.5 0—4.0IU/mL
Anti-thyroid peroxidase antibodies 18.0 0—9.0IU/mL
Anti-TSH receptor antibodies 1.1 <1.8IU/L

4
 GPSN Monash GP Revision Day 2019

MARKING SCHEDULE

Station No: 1
Station title: Hannah Harp
Time allowed: 8 minutes

Management plan:
1 Diagnosis: Hypothyroidism.
State the diagnosis
2 “What do you know about [diagnosis]?”
Establish knowledge
3 “How do you feel about this?”
Establish attitude
4 Role of the thyroid: The thyroid gland sits in the neck and produces thyroid
Educate about diagnosis hormone which helps to speed up or slow down metabolism.

Link to case: Having an underactive thyroid results in too little thyroid

hormone and slows down the metabolism. You can gain weight and feel
tired and cold. It can slow down your heart and your gut which decreases
your appetite and makes you constipated. It can lower your mood and some
people can become depressed. Hypothyroidism is common in people with
Down syndrome which is why thyroid function should be measured each
year.

5 Immediate: Repeat TSH within 2—8 weeks to confirm the diagnosis or

Management plan immediately commence thyroid hormone replacement (levothyroxine).
Levothyroxine is taken as a tablet every day. Start at a low dose and slowly
increase. Check TFTs every 6—8 weeks and adjust the levothyroxine dose
until TSH is in the normal range, then reduce the frequency of monitoring to
every 6—12 months.
Read more: https://www.racgp.org.au/afp/2012/august/hypothyroidism.

To manage constipation, increase Movicol® (macrogol with electrolytes) up

to 3 sachets daily and/or add Coloxyl® (docusate) with senna up to 2 tablets
twice daily, while hypothyroidism is resolving.
Read more:
https://tgldcdp-tg-org-au.ezproxy.lib.monash.edu.au/viewTopic?topicfile=fu
nctional-gastrointestinal-disorders#toc_d1e756

6 Any appropriate, for example offer at the next visit to check blood pressure,
Preventative give the flu vaccine or discuss contraception and STI screening if sexually
opportunities active.

5
 GPSN Monash GP Revision Day 2019

7 Summarise important information and ask Marianne to repeat back the key
Reinforce information points.

8 Offer to print a pamphlet or direct to a reliable website, for example ‘Better

Takeaway information Health Channel: Hypothyroidism’.

9 “How are you feeling now?”

Evaluate consultation “Do you have any questions?”

“Was there anything else today?”

10 Follow-up: Review in 1—2 weeks with Hannah present to assess her directly
Arrange follow-up and check adherence to treatment. Will also need to review in 6 weeks with
repeat TSH results immediately prior to the consultation.

Safety-net: Return to GP if minor concerns or present to ED if serious

concerns, for example unresponsive (due to myxoedema coma; rare) or
suicidal (due to depressed mood).

6
 GPSN Monash GP Revision Day 2019

Serious
errors and
omissions: All important
No attempt,
Inadequate Adequate, areas covered;
or very
SKILLS skill for year but minimal Excellent
cursory
level or incomplete omissions or
adverse errors
effect on
outcome
Communication Skills (4
marks)
● Builds rapport
● Empathic approach
● Avoids jargon
● Delivers information
in small pieces
● Non-verbal
communication

History (6 marks)
● HOPC (3)
● Systems review (1)
● Psychosocial review
(1)
● Down Syndrome
management (0.5 per
point, up to a
maximum of 1)

Investigations (3 marks)
≥3 out of:
● ECG
● FBE
● TFTs
● Thyroid antibodies
● Any other reasonable,
e.g. calcium (3)

Marks to be awarded taking

into account if relevant
investigations have been
ordered, if an appropriate
rationale has been explained
for their choice and for their
correct interpretation.
Management (7 marks)
1. Diagnosis (0.5)
2. Knowledge (0.5)
7
 GPSN Monash GP Revision Day 2019

3. Attitude (0.5)
4. Education: role of the
thyroid gland (0.5),
link to clinical features
(0.5) and Down
syndrome (0.5)
5. Management:
immediate (1).
6. Preventative
opportunities (0.5)
7. Reinforces
information (0.5)
8. Provides takeaway
information (0.5)
9. Evaluates consultation
(0.5)
10. Arranges follow-up
(0.5) and safety-net
(0.5)

Global Scoring:
◻ ◻ ◻
Clear Fail Borderline Clear Pass