GARCIA · Coeliac / TATT

Patient Details

Name: Beatriz / Burty Garcia
Age: 33 years
Opening statement: "I’ve been feeling really run-down recently and not myself at all, so I thought I’d better make an appointment to see what you thought"

Facilitator Notes

Three parts: (1) initial history; (2) explain next steps / investigations with group; (3) results consultation → coeliac diagnosis
TATT is broad — explore systems; note autoimmune family/personal history
Dermatology: clustered excoriated vesicles on elbows (dermatitis herpetiformis)
Resources: NICE CKS – Tiredness/fatigue; Coeliac disease; DermNet – Dermatitis herpetiformis

Clinical Details – Part 1

Open questions — give freely:

Last 6 months: generally more tired and irritable (not like usual self). Sleeps well, often earlier, ~9 hours; sometimes unrefreshed. Wakes feeling good but energy lags by 3 pm — occasional secret 10-minute nap at work. Unintentional 3 kg weight loss over couple of months; no major diet/lifestyle change.

Only if asked directly:

Not depressed/anxious; no eating disorder; normal diet (meat/dairy); normal appetite; doesn’t skip meals
Parkrun times worsened (24 min → struggling under 28 min); enjoys running as stress relief/social
No nausea/vomiting. Heartburn after meals (esp. pizza / macaroni cheese) — Gaviscon helps; tried lactose-free cheese (maybe slightly better). Crampy abdo pain for hours after; no significant bloating
Bowels: used to be constipated; now “runner’s trots” often (once had to dive into bush); no blood/mucus
Breathing and urine normal. Occasional migraines
Intensely itchy rash scalp and elbows last couple of months — E45/Sudocrem soothed a bit; Googled and thinks psoriasis
No mouth ulcers
If female actor: Periods irregular last few months (hardly come); home pregnancy tests negative; breast self-exam normal

Patient Perspective (ICE)

Ideas: Stress-related (tiredness, irritability, weight loss, possible psoriasis). Wonders about dietitian for digestive issues.

Concerns: Having to give up running; going backwards in fitness.

Expectations: Different cream for rash; medication for indigestion and occasional diarrhoea.

Feelings: Irritated more than anything — just wants to get on with life.

Past Medical History

Vitiligo — diagnosed 11 years ago (stable)
IBS — diagnosed 8 years ago

Medication

Gaviscon PRN for indigestion

Family History

Sister — Type 1 diabetes
Mother — Graves’ disease

Social History

Full-time Spanish teacher at private school; pushed toward head of department — unsure if ready
Owns 1-bed flat · No children but wants them someday
Never smoked · Occasional glass of wine
Spanish; in UK 5 years; family still in Spain; good partner/friend support

Demeanour

Normal responses; happy to answer; no irritation unless GP is insensitive or dismissive.

Physical Examination (only if requested)

Conjunctiva slightly pale; nails spoon-shaped in profile
BP 131/77 · Pulse 72 regular · Weight 55 kg · Height 165 cm
Chest / abdo / cardio normal
Elbows: see image (clustered excoriated vesicles — dermatitis herpetiformis)

Information for the Student – Part 1

Name: B Garcia · Age 33
PMH: Vitiligo 11 yrs (stable) · IBS 8 yrs
Medication: Nil regular (Gaviscon PRN)
Recent: 6 months: angular cheilitis (clotrimazole) · 5 years: new patient (Ht 165, Wt 59 kg)

Part 2 – Results Consultation

Keen to know results. Push for a clear diagnosis of coeliac disease if not stated; ask how diagnosis is known (bloods + symptoms). Questions if not covered:

What this means going forward / next steps
Specialist referral? Who?
Will symptoms go away with treatment?
Long-term complications?
Will the rash go away?

Key results (give if requested):
Hb 102 (low) · Ferritin 6 (low) · TTG POSITIVE · IgA 2.5 · ESR 29 · Platelets 422
TSH normal · eGFR >90 · LFTs essentially normal · Stool culture / FIT / faecal calprotectin negative

Primary Care Block · University of Buckingham