The University of Adelaide, Adelaide Medical School Yr 1 Clinical Practice

Year 1 Case History Charlotte Brown

Case 8

Charlotte Brown
Female, 40
DOB: 21/2/1979
Address: 45 Farmer St. Port Adelaide

Setting: GP clinic
Patient looks well, slightly pale but not distressed

Overview
You have come to see your GP today because you have been feeling tired all the time
for about 3 months and it is getting worse.
The only other symptom you have had is very heavy periods.

Patient perspective: I’m worried that I won’t be able to manage my new job as I feel
really tired

Opening line: “I’ve been feeling really run down for a while now.”

 You been feeling increasingly tired over the last 3 months.

 The only other symptom you have had is some change in your period. It still
comes every 28 days but they have been particularly heavy. You have been
using perhaps 6 pads per day on the first 3 days or so (normally only 2-3) and
your periods have lasted 7 days rather than the usual 4 days.
 You first started having periods at age 12.
 You have not lost any weight.
 You are a vegetarian and love eating fresh fruits and vegetables.
 You haven’t noticed any blood in your stools but you never look. You have
been having normal bowel motions of a normal colour
 You have been feeling a little short of breath when you walk a long way but
have not been having any chest pain.
 You have not been feeling depressed just really tired.

Past History
 Eczema
 Hayfever
 Grommets as a child
Medication
 Budesonide nasal spray one puff in the mornings if needed (for hayfever)

Smoking
You do not smoke cigarettes and have never done

Clinical Practice 2017 Originally written by Dr Andrew Linn

The University of Adelaide, Adelaide Medical School Yr 1 Clinical Practice
Year 1 Case History Charlotte Brown

Alcohol
You drink the occasional wine with friends (3-4 wines a week)
Drugs
Never used

Social history
 You are a physiotherapist. Your hours have been quite long lately.
 You are married with 1 son aged 4.
 Your husband is currently unemployed, but he can look after your son
 Diet- vegetarian
 Exercise – non-existent as you are too busy

Family History
 You father has a bit of high blood pressure but is otherwise well.
 Your mother had breast cancer diagnosed 5 years ago that was treated. She
has remained well since without any signs of recurrence.
 2 brothers are well except both have asthma

Diagnosis (for Tutor)

Anaemia likely secondary to a number of factors including increased blood loss
(heavy periods) and possibly low intake of iron (vegetarian).

Discussion points (for tutor if time permits)

Likely physical examination findings in this patient

Clinical Practice 2017 Originally written by Dr Andrew Linn