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This is a long case.

Please take a history from Shirley. You are expected to tell her your diagnosis and negotiate a management plan with her.


A young mum, Shirley Hill, has arranged for a neighbour to look after her children so she can see a GP. She has been feeling tired all the time since the birth of her second child. She has just moved to the area. Just before she moved she went to her previous GP who did the following tests for tiredness which were all normal: FBC, ESR, UEC, TFTs, BSL, iron studies and urine for MCS.

The following information is on her summary sheet, which she brought from her previous GP:

  • Past medical history

  • First child, two years ago

  • Second child, six months ago

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Cervical screening test

  • Normal this year

  • Social history

  • Ex-nurse

  • Husband—Bill, a businessman, travels interstate regularly

  • Non-smoker

  • Alcohol intake—30 standard drinks per week recorded three years ago.


You used to work as a nurse. You enjoyed your work as a clinical nurse consultant at a major teaching hospital. You met Bill when he was just starting up his own business. You brought in the regular income so he could spend time promoting the company before it became profitable. Over the last few years the business has thrived but has taken up more and more of his time. Because he is away so much you have had to give up your casual shifts at the local hospital.

Since the birth of your second child you have been feeling exhausted. You are getting some sleep but not as much as you need. You fall asleep as soon as your head hits the pillow. You are not refreshed when you wake up. You often get up around 3–4 am, sometimes it’s for a breastfeed, but lately your baby is sleeping through and you’re still waking up. It’s difficult to get to sleep after this. You are finding it difficult to concentrate and have forgotten to pay a phone bill and power bill lately, which is really out of character.

You always wanted to be a mum, but it feels like more of a chore at present, which you feel guilty about. Other mums seem to have it all together. You don’t want to admit it, but often you shout at the children and spend hours wondering what’s gone wrong in life. You have a beautiful home and wonderful children but feel miserable and resentful and just can’t be bothered any more.

You don’t have much of an appetite lately and are still losing your baby weight.

You have no friends to share child care with as you ...

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