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This is a long case.

Please take a history from Jeanette. Examination findings will be available from the facilitator. Discuss with Jeanette your differential diagnosis and identify her issues that need to be addressed. Negotiate a management plan with her. No investigations will be available but a request for these may be part of your management plan.


Mrs Jeanette Wilkinson is a 48-year-old personal care worker at a residential aged care facility. Jeanette and her family have been attending your practice, in a small regional town, for several years, although Jeanette rarely attends for herself.

The following information is on her summary sheet:

  • Past medical history

  • G3P2M1: Two spontaneous vaginal deliveries (healthy babies), one miscarriage

  • Medication

  • Nil regular

  • Allergies

  • Nil known

  • Immunisations

  • None recorded

  • Family history

  • Father myocardial infarction age 65

  • Social history

  • Personal care worker at a residential aged care facility

  • Lives on a farm outside of town

  • Cervical screening

  • Up-to-date and normal.


You are coming to talk to your GP about a test for the MTHFR gene. A friend of yours mentioned it and, from what you’ve read on the internet, it sounds like this could explain some of your problems. You have been feeling fatigued and run-down, getting progressively worse over the last two to three years. You are worried, as the website you read states the MTHFR gene can be associated with many of the symptoms and problems you or your family have experienced. For example: miscarriages (you’ve had one), heart attacks (your dad), fatigue, concentration problems and ADHD (your 12-year-old son has been diagnosed with this and you have struggled with his behaviour for many years). You are hopeful that there might be an answer to all your problems.

You have another child, a 15-year-old daughter. You have some worries about the friends she is starting to hang around with and the way she is dressing, but she is generally a good kid. You work full-time doing long, irregular shifts in the residential aged care facility.

You live 20 km out of town and run a small family farm with some cattle and sheep. Your time away from ‘real work’ is taken up with farm work. The farm is a major stress for you and is losing money financially. You are working outside of the farm to be able to cover the bills. Your husband has finally agreed to try to sell it, and it is on the market, but so far you have not had any interested buyers. You haven’t been on a holiday longer than one night away in over ten years.

You feel you are depressed, probably worsening over the last six months, and you often cry in the mornings when you are alone ...

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