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MD2 Ambulatory Care and Emergency Medicine > A Case of Lethargy > Flashcards

A Case of Lethargy Flashcards

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1
Q

What are some of the differential diagnoses for lethargy and fatigue?

A 
Anaemia
Malnutrition
Poor sleep
Depression
Hypothyroidism
Cancer
Infection
Chronic allergies
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2
Q

What differential diagnosis should always be included?

A

Mental health problem

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3
Q

What are you reminding yourself of when you include an “environmental” differential?

A

Never forget a patient’s context

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4
Q

Are tests useful in investigating tiredness?

A

No

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5
Q

What is one consideration for basing test decisions?

A

Pre-test probability

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6
Q

If gastrointestinal cancer is high on the list, what investigation needs to be done?

A

Gastroscopy and/or colonoscopy for histological examination

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7
Q

What can LFTs give an indication of?

A

Status of
- Nutrition
- Chronicity
Via albumin and protein levels

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8
Q

What are CT scans not very good for?

A

Looking at hollow viscera

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9
Q

What is the standard investigation for staging rectal cancer?

A

MRI

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10
Q

What does the PROMPT acronym stand for

A 
P = probability diagnosis
R = red flags
O = often missed
M = masquerades
PT = patient trying to tell you something
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11
Q

What disease should you always test for in anaemia?

A

Coeliac disease

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12
Q

What diseases do you see pencil cells in the blood film in?

A

Fe deficiency anaemia
Thalassaemia
Pyruvate kinase deficiency

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13
Q

In what sort of patient is faecal occult blood test a screening tool?

A

Asymptomatic patient

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14
Q

What are the symptoms of chronic anaemia?

A

(Exertional) dyspnoea
Fatigue
Signs and symptoms of hyperdynamic circulation

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15
Q

What are the signs and symptoms of hyperdynamic circulation?

A

Bounding pulses
Palpitations
Worsening symptoms if underlying heart/lung disease

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16
Q

What is the classification of anaemia by pathophysiology?

A

Blood loss
Decreased production
Increased destruction

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17
Q

What are the causes of blood loss?

A 
GI tract
Urinary
Menstrual loss
Chronic recurrent epistaxis
Hereditary arteriovenous malformation
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18
Q

What are the causes of decreased production?

A 
Anaemia of chronic disease
Bone marrow infiltration
Endocrine
- Hypothyroidism
- EPO deficiency
Nutritional deficiency
- B12
- Folate
- Fe
Infectious
- Acute
- Chronic
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19
Q

What are possible symptoms of anaemia due to blood loss?

A 
Haematemesis
Melena
Change in bowel habit
Tenesmus
PR bleeding
Weight loss
Heavy menstruation
20
Q

What are possible dietary causes of anaemia?

A

Vegan
Vegetarian
Coeliac
Parasite infection

21
Q

What are some symptoms of bone marrow failure?

A 
Bleeding
Infection
Fevers
Sweats
Weight loss
History of radiation
Prior malignancy
22
Q

What are some symptoms of increased RBC destruction?

A 
Dark urine
Jaundice
Gall stones
Family history of splenectomy
Cholycystectomy
23
Q

What is the classification of anaemia by morphology?

A

Normochromic normocytic
Microcytic hypochromic
Macrocytic

24
Q

What defines microcytic anaemia?

A

MCV <80

25
Q

What are possible causes of microcytic anaemia?

A

Reduced Fe availability
Reduced haeme synthesis
Reduced globin production

26
Q

What are possible causes of iron deficiency?

A

Fe deficient diet
Malabsorption of Fe
Increased Fe requirements
Blood loss

27
Q

What can affect haeme synthesis?

A

Lead poisoning

Acquired/congenital sideroblastic anaemia

28
Q

Define basophilic stippling

A

Small dots in periphery of RBCs

= ribosomes

29
Q

What is a sign of haeme synthesis on the blood film?

A

Basophilic stippling

30
Q

What can affect globin production?

A

Thalassaemias

31
Q

What are the signs of thalassaemia on the blood film?

A

Hypochromia
Microcytosis
Target cells
Tear drops

32
Q

What do iron studies in iron deficiency anaemia show?

A

Serum Fe = decreased
Transferrin/TIBC = increased
Serum ferritin = decreased
Soluble transferrin receptor = increased

33
Q

What do iron studies in anaemia of chronic disease show?

A

Serum Fe = decreased
Transferrin/TIBC = decreased
Serum ferritin = increased
Soluble transferrin receptor = normal/decreased

34
Q

What do iron studies in thalassaemia show?

A

Serum Fe = normal
Transferrin/TIBC = normal
Serum ferritin = normal
Soluble transferrin receptor = increased

35
Q

What are the clinical features of iron deficiency anaemia?

A 
Fatigue
Pallor
Exertional dyspnoea
Koilonychia
Angular cheilosis
Glossitis
36
Q

What are the causes of hypochromic microcytic anaemia?

A 
Fe deficiency
Thalassaemia
Sickle cell disease
Pb poisoning
Sideroblastic anaemia
37
Q

What are the causes of normochromic normocytic anaemia?

A

Anaemia of chronic disease
Haemolysis
Renal failure
Pregnancy dilution

38
Q

What are the causes of macrocytic anaemia?

A 
B12/folate deficiency
Alcoholism
Liver disease
Drugs
Hypothyroidism
Myeloma
39
Q

What are the investigations for haemolytic anaemia?

A 
LDH - elevated
Unconjugated bilirubin - elevated
Haptoglobin - redued
Blood film
- Spherocytes
- Bite cells
- Fragments
- Nucleated red cells
- Polychromasia
Direct Coombs test - detection of RBC Abs
Urinary free Hb
Plasma free Hb
40
Q

What are the features of intravascular haemolysis?

A

Blood film fragmentation
Haemoglobinaemia
Haemosidinuria

41
Q

What are the causes of intravascular haemolysis?

A 
Disseminated intravascular coagulation
Sepsis
Cardiac valvular disease
Paroxysmal nocturnal haemoglobinuria
Extracorporeal circulation
Thrombotic thrombocytopaenic purpura/haemolytic uraemic syndrome
Disseminated malignancy
Arteriovenous malformations
42
Q

What are the clinical features of extravascular haemolysis?

A

Spherocytes
Bite cells
Sickle cells

43
Q

What are the non-immune causes of extravascular haemolysis?

A

Hypersplenism
Red cell membrane disorders
Red cell enzyme disorders

44
Q

What are some immune causes of extravascular haemolysis?

A

Cold agglutinin disease - IgM

Warm agglutinin disease - IgG

45
Q

How is haemolysis treated?

A 
Corticosteroids
IVIg
Immunosuppression
Rituximab
Splenectomy
Dapsone
Anabolic steroids
46
Q

What is rituximab?

A

Anti-CD 20 mAb

MD2 Ambulatory Care and Emergency Medicine (29 decks)

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