Cases/Maternity and Reproductive Health

Abnormal Thyroid Result — Free SCA Practice Case

Pregnant woman with an abnormal thyroid result

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Claire Donnelly

Age

35 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Seen by the practice nurse practitioner 3 days ago for fatigue; bloods are now back and the patient has booked a call to discuss them.

Reason for Encounter

"I've booked to go through my blood results. I've been exhausted for weeks and I want to know what's causing it and what I can do."

Medical Records

●PMH: Nil. Currently pregnant (9 weeks). Gravida 1, para 0.
●Medications: Folic acid 400 micrograms OD (started by nurse practitioner).
●Allergies: NKDA.
●Nurse-practitioner note (3 days ago): 9 weeks pregnant; 6 weeks of persistent tiredness, no other symptoms. BP 110/70, BMI 24, urinalysis negative. Impression: likely pregnancy-associated tiredness. Bloods to exclude vitamin deficiency/other causes.
●Blood results (for filing): TSH 5.8 mU/L (ref 0.4–4.0). Free T4 11 pmol/L (ref 9–24). Hb 12.2 g/dL. Ferritin 50 µg/L. B12 and folate normal. U&E, LFTs, CRP, HbA1c, ESR normal. Impression: subclinical hypothyroidism.

Patient Script

For the friend playing the patient role

Character Overview: You are Claire, a 35-year-old secondary-school teacher, 9 weeks into your first pregnancy. You have been exhausted for about six weeks. You saw a nurse practitioner who did blood tests, and you are ringing for the results. You are excited about the pregnancy but worried something is wrong, and anxious the tiredness will force you into early maternity leave, which you do not want. You are cooperative and want a clear explanation and a solution.

Opening Sentence: "Hi Doctor. I saw the nurse a few days ago because I've been absolutely shattered for weeks, and she did some blood tests. I'm nine weeks pregnant. I'm ringing to find out what the results showed and whether there's anything I can do — the tiredness is really affecting my teaching."

History if Asked (Data Gathering Phase)

●The tiredness: "I've been exhausted for about six weeks — more than I'd expect even being pregnant. It's affecting my work."
●Other symptoms (only if asked): "Now you mention it, I have been feeling the cold more, and maybe a bit constipated. My skin's a bit dry. I hadn't linked those together."
●The pregnancy: "First pregnancy, nine weeks, planned, going well otherwise. I'm booked with the midwife and my first scan's in about three weeks."
●Family history (only if asked): "My sister had an underactive thyroid when she was pregnant, actually."
●What she wants: "I just want to know what's causing the tiredness and to feel better — and to keep working as long as I can."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Claire has been told the tiredness is "just pregnancy," which she has half-accepted, though as a first-timer she is unsure what is normal. "The nurse said it was probably just the pregnancy. I don't really know what's normal, being my first."
●Concerns: She is worried something is wrong, and specifically that the tiredness will force her into early maternity leave, which she does not want. "I'm worried it's something more, and honestly I'm scared I'll have to go off work early, which I really don't want."
●Expectations: She wants her results explained and a solution to help her feel better. "I want to understand the results and to have something done that helps."

If Asked — Medical History and Symptoms

The patient confirms these details only when directly asked.

●Hypothyroid symptoms: "Tired, feeling the cold, dry skin, a bit constipated. No real weight change beyond the pregnancy. Mood's okay."
●Worsening since NP: "About the same, maybe slightly worse."
●Pregnancy symptoms: "Some nausea, no bleeding, no tummy pain."
●Medications: "Just the folic acid the nurse started. Nothing else, no over-the-counter things."
●Family history: "Sister had a thyroid problem in pregnancy."
●Allergies: "None."

Social History and Lifestyle Impact

Claire is a secondary-school teacher. She lives with her husband. First pregnancy.

●Work: "Teaching is demanding, and the tiredness is really affecting me — I'm struggling to get through the day."
●Home/support: "Live with my husband, supportive, good relationship."
●Lifestyle: "Non-smoker, no alcohol now I'm pregnant."
●Impact: "Exhausted, worried about work and about the baby."

Responses to Management (The Negotiation Phase)

●If the Doctor explains subclinical hypothyroidism: "So my thyroid's a bit underactive? Is that serious? Is it why I'm so tired?" (The tested point is explaining subclinical hypothyroidism in plain terms and its relevance in pregnancy.)
●If the Doctor recommends checking TPO antibodies and treating with levothyroxine: "Would I need to take medication? Is it safe in pregnancy?" (The tested point is explaining the treatment, seeking specialist advice, and reassuring that levothyroxine is safe in pregnancy.)
●If the Doctor mentions specialist/endocrine advice: "Do I need to see a specialist, or can you sort it here?"
●If the Doctor explains the fetal implications: "Could this have affected the baby? Is the baby okay?"
●If the Doctor advises on taking levothyroxine and follow-up: "How do I take it, and how will we know it's working?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Subclinical Hypothyroidism

●Subclinical hypothyroidism is a raised TSH with a normal free T4 — the thyroid is mildly underactive. Symptoms (fatigue, cold intolerance, dry skin, constipation) may be present or absent.
●Check thyroid peroxidase antibodies (TPOAb), which indicate autoimmune thyroid disease and inform management.

Why Pregnancy Changes the Threshold

●In pregnancy, the fetus depends on maternal thyroid hormone, especially in the first trimester, for neurodevelopment. Untreated thyroid dysfunction is associated with adverse pregnancy outcomes.
●TSH targets are lower/tighter in pregnancy (broadly aiming for a first-trimester TSH around <2.5 mU/L, or within trimester-specific/lab reference ranges), and subclinical hypothyroidism is treated more readily than outside pregnancy.

Treatment and Specialist Advice

●Levothyroxine is used to treat subclinical hypothyroidism in pregnancy to improve outcomes, particularly in TPOAb-positive women; specialist/endocrine advice should be sought around initiation.
●(Clinical note: the benefit of treating TPOAb-negative subclinical hypothyroidism is debated — follow current NICE/endocrine guidance and local pathways.)
●Levothyroxine is safe in pregnancy and requirements often increase as pregnancy progresses.

Taking Levothyroxine

●Take on an empty stomach, at least 30–60 minutes before food, and at least 4 hours apart from iron or calcium supplements, which reduce absorption.

Monitoring

●Recheck thyroid function ~4 weeks after starting or adjusting treatment, and monitor through pregnancy, titrating to the trimester-specific target.

Standard Pregnancy Advice

●Folic acid (400 micrograms, or 5 mg if high risk) and vitamin D (10 micrograms daily). Offer pregnancy vaccinations: flu and COVID at any time, pertussis from 16 weeks, RSV from 28 weeks.

Excluding Other Causes of Fatigue

●Fatigue in pregnancy is common, but a normal FBC, ferritin, B12, and folate with a raised TSH points to the thyroid — a reminder to interpret the whole panel rather than attributing tiredness to pregnancy by default.

Common Candidate Mistakes in This Case

●Dismissing it as "just pregnancy": missing the treatable thyroid abnormality behind the fatigue.
●Misinterpreting the results: failing to recognise subclinical hypothyroidism, or over-calling it as overt disease.
●Not seeking specialist advice / not checking TPOAb: initiating (or withholding) treatment without the appropriate work-up and advice.
●Wrong levothyroxine counselling: omitting the empty-stomach and iron/calcium-spacing advice, or the pregnancy TSH target and follow-up.
●Alarming her about the baby: implying harm has been done rather than explaining that treatment reduces risk.

Free MRCGP SCA practice case for GP registrars covering Abnormal Thyroid Result — Maternity and Reproductive Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

← Back to Free SCA Practice Cases