1. Clinical dialogue five Xiao Xiong Li Department of neurological Surgery Ren Ji Hospital

2. Part one D: I see from your notes you were in hospital 10 years ago with thyroid trouble. P: Yes, that’s right. D: What has actually been happening since that? P: All sorts of things. I’ve been feeling very depressed for a year. D: Did you go to your doctor? P: Yes, he gave me some Valium tablets to slow me down but they slowed me to a halt. I did nothing but sleep.

3. D: Did they affect you in any other way? P: Yes, I got stomach trouble, maybe indigestion, I think. D: What symptoms? P: All the food stays up here. (indicating chest) D: When do you get it? P: Two to three hours after food.

4. D: Burning or stabbing pain? P: It feels like some wind there and I want to get rid of it. D: Do you belch? P: Not much. D: Does it bother you at night? P: No, it comes on when I was hungry and I feel I’ll collapse if I don’t eat straight away

5. D: How about your appetite? P: Very poor, it started to deteriorate 10 years ago. D: What about your weight? P: I’m loosing weight. D: What about your bowels? P: I’m constipated.

6. D: How often do you have them opened? P: Only when I take medicine. D: Every day? P: No, every other day. D: Do you always sweat? P: Yes, but more recently. D: All over you body? P: Yes, all over.

7. D: Any depressed, nervous, edgy, irritable? P: Yes, it started one month ago before I got my job. D: Periods regular? P: Every month since I had my baby five years ago.

8. D: Is there anything else you’ve noticed ? P: No. D: Has anyone in your family had thyroid trouble? P: No, I have one sister and two brothers, they are well.

9. Part two D: I see you’ve been anaemic and you had a blood test last May. Has anything else trouble you? P: I’ve kept getting a roaring in my ears and giddiness. D: All the time? P: Most of the time. D: How long has all this gone on? P: Say, about six months.

10. D: Since your treatment with iron? P: Yes, I keep getting dizzy spells. D: Does anything bring them on? P: Rushing about. Sometimes I know I’m falling but I can’t stop myself. D: Do your legs give way? P: Yes. D: If you stand still, do you hold on? P: Yes.

11. D: Are you all right between spasms? P: Yes. D: Does it affect your ears? P: I get roaring in my ears. D: How long? P: Minutes. D: Do you feel sick? P: Yes, first thing in the morning. Terribly.

12. D: Do you suffer from headaches? P: My periods are only half a day and I get terribly headaches. D: How often do you have your periods? P: It varies, every two or three weeks. D: Is it always like that? P: Yes. D: You say you are breathless? P: Yes, I get puffed if I go upstairs.

13. D: Do you have any bowel trouble? P: No. D: Water? P: No. D: Do you get up at night? P: No.

14. Part three D: I see from your notes you came to us a year ago with an overactive thyroid gland. P: Yes, and I had a miscarriage in May and I’m now pregnant again. D: When is your baby due? P: Roughly 10th July. D: Have you been taking pills for your gland? P: I stopped about six months ago.

15. D: How are you at the moment? P: I keep feeling queer and my doctor suggested I had a check-up. D: Do you ever faint? P: No, but I feel faint. D: Do you actually flush or sweat? P: No, not as before.

16. D: Have you been gaining weight? P: Yes, I didn’t realise I was pregnant. D: Are your bowels regular? P: Yes. D: Do you go more than once a day? P: No. D: They are quite well-formed, are they? P: Yes.

17. D: How are your nerves? Are you jittery, fidgety? P: No. D: Do the family get on your nerves? P: Not now. D: Were your eyes always prominent? P: Yes.

18. D: Are you particularly bothered by weather? P: No, I used to be before. D: You suffer from palpitations? P: Yes, but I’ve had them since I was a child. D: In yourself, you feel different? P: Oh, yes.