This script includes two mock cases focusing on weight changes — one standard case of unintentional weight loss and one tricky case of subtle endocrine weight gain. Ideal for practicing clinical reasoning, history taking, and English communication.
🟩 Case 1 – “I eat the same, but my pants keep getting looser.”
Doorway Information
- Name: Karen T.
- Age / Gender: 65-year-old female
- Chief Complaint: “I’m losing weight without trying.”
- Vital Signs: T 37.0°C, HR 102 bpm, BP 134/76, RR 16, SpO₂ 98%
Opening
“Well, I’ve dropped about 5 kilograms in the last two months, but I haven’t changed anything about my eating. My clothes are hanging off me now.”
Shoreline
“It started around two months ago. I noticed I was losing weight even though I kept eating normally. That’s why I came in.”
Structured History
- Mood: Feels energetic but irritable
- Function: More active than usual
- Appetite: Increased, craves sweets
- Sleep: Fragmented, hot at night
- P: Mild hypertension
- A: No known allergies
- M: Amlodipine 5mg daily
- H: None
- I: Old ankle sprain
- T: No trauma history
- S: C-section only
- F: Mother had thyroid issue
- O: Menopause at 51
- S: Sleeps 5h, no smoking, wine x1/wk
- S: Not sexually active
Physical Examination
- Fine tremor, brisk reflexes, warm skin
- Soft diffuse goiter
- No exophthalmos, no focal deficits
Differential Diagnosis
- Graves’ Disease – weight loss with appetite, tremor, goiter
- Diabetes Mellitus – no polyuria/dipsia, less likely
- Malignancy – no red flag signs
Clinical Reflection
“She seems more energetic than sick — classic hyperthyroidism. Labs will confirm Graves’.”
Clinical Pearls
- Weight loss + increased appetite → consider thyroid
- Goiter without tenderness = think autoimmune
- Tremor + reflexes = neurologic clues
Challenging Questions
Q: “Is this cancer?”
A: “That’s one possibility, but we need more information. There are several other conditions that can cause this. We’ll do the right tests to rule things out. You’re not alone—we’ll go through this step by step.”
📝 SOAP Note
S:
65-year-old female presents with 2-month history of unintentional 5–6 kg weight loss despite increased appetite. Reports mild irritability, insomnia, frequent hunger, and recent fine hand tremor noticed by daughter. Denies fever, pain, polyuria, GI or respiratory symptoms.
O:
- Vitals: T 37.0°C, HR 102 bpm, BP 134/76, RR 16, SpO₂ 98%
- General: Alert, mildly anxious
- Neck: Diffuse, soft, non-tender goiter; no bruit
- Neuro: Fine tremor in outstretched hands, brisk reflexes
- Skin: Warm, moist palms
- No lid lag, exophthalmos, or lymphadenopathy
A:
# Unintentional weight loss with preserved/increased appetite
# Fine tremor and hyperreflexia
# Soft diffuse goiter without pain
# Restlessness and insomnia without mood disorder
ddx): Graves' disease, new-onset diabetes mellitus, occult malignancy
r/o): DM (no polyuria/polydipsia), malignancy (no red flags or systemic signs)
→ Most consistent with Graves' disease (hyperthyroidism). Plan to confirm with labs and initiate symptomatic treatment.
P:
- Labs: TSH, Free T4, T3, TSI, CBC, CMP
- ECG to assess for tachyarrhythmia
- Start propranolol 10–20 mg TID PRN for tremor/palpitations
- Thyroid US if nodularity later found
- Endocrinology referral for definitive management
🟥 Case 2 – “I haven’t changed anything, but I’m gaining weight.”
Doorway Information
- Name: Lisa M.
- Age / Gender: 48-year-old female
- Chief Complaint: “I keep gaining weight even though I haven’t changed anything.”
- Vital Signs: T 36.8°C, HR 88 bpm, BP 148/92, RR 14, SpO₂ 99%
Opening
“I’m not doing anything different, but I keep putting on weight, and it’s really bothering me.”
Shoreline
“I think it started about six months ago. My face and belly seem bigger, and the number on the scale keeps climbing. I just don’t know why.”
Structured History
- Mood: Frustrated and anxious
- Function: Sluggish, tired
- Appetite: Unchanged
- Sleep: Early awakening
- P: Hypertension
- A: None
- M: Losartan 50mg daily
- H: Only for childbirth
- I: None
- T: No trauma
- S: C-section at 32
- F: DM and heart disease
- O: Irregular periods
- S: Office worker, stressed, no smoking
- S: Married, monogamous
Physical Examination
- Moon face, truncal obesity
- Violaceous striae on abdomen
- BP elevated, normal neuro exam
Differential Diagnosis
- Cushing Syndrome – striae, central obesity, HTN
- Hypothyroidism – less likely, no bradycardia/cold intolerance
- PCOS – age, absence of hirsutism
Clinical Reflection
“Those striae and moon face point to cortisol excess — this isn’t just stress-related weight gain.”
Clinical Pearls
- Not all weight gain is lifestyle
- Violaceous striae = Cushing until proven otherwise
- Check meds: steroids are common causes
Challenging Questions
Q: “Am I just getting fat because I’m getting older?”
A: “Age can play a role, but the signs you’re describing—like the purple stretch marks and facial swelling—aren’t typical aging. Let’s check your hormone levels and make sure nothing serious is going on.”
📝 SOAP Note
S:
48-year-old female presents with gradual progressive weight gain over 6 months, particularly in the face and abdomen. Denies lifestyle or dietary changes. Reports facial puffiness, new purple stretch marks on abdomen, irregular menses, early morning awakening, and fatigue. Denies use of corticosteroids or supplements.
O:
- Vitals: T 36.8°C, HR 88 bpm, BP 148/92, RR 14, SpO₂ 99%
- General: Appears tired, centrally obese
- Face: Rounded (moon face), mild erythema
- Abdomen: Wide violaceous striae (2–3 cm)
- Skin: Easy bruising on upper arms
- Extremities: Thin limbs; strength and reflexes normal
- No hirsutism, no acne, no proximal weakness
A:
# Central weight gain with thin extremities
# Facial fullness (moon face), violaceous abdominal striae
# Menstrual irregularity
# No exogenous steroid use
ddx): Cushing syndrome (ACTH-dependent or adrenal), hypothyroidism, PCOS
r/o): Hypothyroidism (no cold intolerance, bradycardia), PCOS (no hirsutism or acne)
→ Most consistent with endogenous Cushing syndrome. Requires hormonal work-up to confirm cortisol excess and guide further imaging.
P:
- Initial work-up: 1 mg overnight dexamethasone suppression test, morning cortisol, ACTH
- Additional labs: 24-hour urine cortisol, CBC, CMP, TSH
- Imaging: Consider pituitary MRI or adrenal CT pending results
- Monitor BP, refer endocrinology
📚 Related Articles
- Mock Patient Script – Paralysis
- Approach to Weight Change: “I’ve Been Losing Weight…”—Is It Really Diet Success?
- 🩺 Mock Patient Scripts
📖 References
- UpToDate: “Approach to unintentional weight loss” / “Cushing syndrome: Clinical manifestations”
- Harrison’s Principles of Internal Medicine, 21st Edition
📘 Recommended Study Resources
- First Aid for the USMLE Step 2 CS – Excellent for physical signs and SOAP structure
- ダ・ヴィンチのカルテ – 思考過程を鍛える日本語の臨床推論書
- ティアニー先生の臨床入門 – 症候から考える総合診療の基本