A Case of Lethargy Flashcards
What are some of the differential diagnoses for lethargy and fatigue?
Anaemia Malnutrition Poor sleep Depression Hypothyroidism Cancer Infection Chronic allergies
What differential diagnosis should always be included?
Mental health problem
What are you reminding yourself of when you include an “environmental” differential?
Never forget a patient’s context
Are tests useful in investigating tiredness?
No
What is one consideration for basing test decisions?
Pre-test probability
If gastrointestinal cancer is high on the list, what investigation needs to be done?
Gastroscopy and/or colonoscopy for histological examination
What can LFTs give an indication of?
Status of
- Nutrition
- Chronicity
Via albumin and protein levels
What are CT scans not very good for?
Looking at hollow viscera
What is the standard investigation for staging rectal cancer?
MRI
What does the PROMPT acronym stand for
P = probability diagnosis R = red flags O = often missed M = masquerades PT = patient trying to tell you something
What disease should you always test for in anaemia?
Coeliac disease
What diseases do you see pencil cells in the blood film in?
Fe deficiency anaemia
Thalassaemia
Pyruvate kinase deficiency
In what sort of patient is faecal occult blood test a screening tool?
Asymptomatic patient
What are the symptoms of chronic anaemia?
(Exertional) dyspnoea
Fatigue
Signs and symptoms of hyperdynamic circulation
What are the signs and symptoms of hyperdynamic circulation?
Bounding pulses
Palpitations
Worsening symptoms if underlying heart/lung disease
What is the classification of anaemia by pathophysiology?
Blood loss
Decreased production
Increased destruction
What are the causes of blood loss?
GI tract Urinary Menstrual loss Chronic recurrent epistaxis Hereditary arteriovenous malformation
What are the causes of decreased production?
Anaemia of chronic disease Bone marrow infiltration Endocrine - Hypothyroidism - EPO deficiency Nutritional deficiency - B12 - Folate - Fe Infectious - Acute - Chronic
What are possible symptoms of anaemia due to blood loss?
Haematemesis Melena Change in bowel habit Tenesmus PR bleeding Weight loss Heavy menstruation
What are possible dietary causes of anaemia?
Vegan
Vegetarian
Coeliac
Parasite infection
What are some symptoms of bone marrow failure?
Bleeding Infection Fevers Sweats Weight loss History of radiation Prior malignancy
What are some symptoms of increased RBC destruction?
Dark urine Jaundice Gall stones Family history of splenectomy Cholycystectomy
What is the classification of anaemia by morphology?
Normochromic normocytic
Microcytic hypochromic
Macrocytic
What defines microcytic anaemia?
MCV <80
What are possible causes of microcytic anaemia?
Reduced Fe availability
Reduced haeme synthesis
Reduced globin production
What are possible causes of iron deficiency?
Fe deficient diet
Malabsorption of Fe
Increased Fe requirements
Blood loss
What can affect haeme synthesis?
Lead poisoning
Acquired/congenital sideroblastic anaemia
Define basophilic stippling
Small dots in periphery of RBCs
= ribosomes
What is a sign of haeme synthesis on the blood film?
Basophilic stippling
What can affect globin production?
Thalassaemias
What are the signs of thalassaemia on the blood film?
Hypochromia
Microcytosis
Target cells
Tear drops
What do iron studies in iron deficiency anaemia show?
Serum Fe = decreased
Transferrin/TIBC = increased
Serum ferritin = decreased
Soluble transferrin receptor = increased
What do iron studies in anaemia of chronic disease show?
Serum Fe = decreased
Transferrin/TIBC = decreased
Serum ferritin = increased
Soluble transferrin receptor = normal/decreased
What do iron studies in thalassaemia show?
Serum Fe = normal
Transferrin/TIBC = normal
Serum ferritin = normal
Soluble transferrin receptor = increased
What are the clinical features of iron deficiency anaemia?
Fatigue Pallor Exertional dyspnoea Koilonychia Angular cheilosis Glossitis
What are the causes of hypochromic microcytic anaemia?
Fe deficiency Thalassaemia Sickle cell disease Pb poisoning Sideroblastic anaemia
What are the causes of normochromic normocytic anaemia?
Anaemia of chronic disease
Haemolysis
Renal failure
Pregnancy dilution
What are the causes of macrocytic anaemia?
B12/folate deficiency Alcoholism Liver disease Drugs Hypothyroidism Myeloma
What are the investigations for haemolytic anaemia?
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
What are the features of intravascular haemolysis?
Blood film fragmentation
Haemoglobinaemia
Haemosidinuria
What are the causes of intravascular haemolysis?
Disseminated intravascular coagulation Sepsis Cardiac valvular disease Paroxysmal nocturnal haemoglobinuria Extracorporeal circulation Thrombotic thrombocytopaenic purpura/haemolytic uraemic syndrome Disseminated malignancy Arteriovenous malformations
What are the clinical features of extravascular haemolysis?
Spherocytes
Bite cells
Sickle cells
What are the non-immune causes of extravascular haemolysis?
Hypersplenism
Red cell membrane disorders
Red cell enzyme disorders
What are some immune causes of extravascular haemolysis?
Cold agglutinin disease - IgM
Warm agglutinin disease - IgG
How is haemolysis treated?
Corticosteroids IVIg Immunosuppression Rituximab Splenectomy Dapsone Anabolic steroids
What is rituximab?
Anti-CD 20 mAb
