A Case of Lethargy

Question 1

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

Answer 1

Anaemia
Malnutrition
Poor sleep
Depression
Hypothyroidism
Cancer
Infection
Chronic allergies

Question 2

What differential diagnosis should always be included?

Answer 2

Mental health problem

Question 3

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

Answer 3

Never forget a patient’s context

Question 4

Are tests useful in investigating tiredness?

Answer 4

No

Question 5

What is one consideration for basing test decisions?

Answer 5

Pre-test probability

Question 6

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

Answer 6

Gastroscopy and/or colonoscopy for histological examination

Question 7

What can LFTs give an indication of?

Answer 7

Status of
- Nutrition
- Chronicity
Via albumin and protein levels

Question 8

What are CT scans not very good for?

Answer 8

Looking at hollow viscera

Question 9

What is the standard investigation for staging rectal cancer?

Answer 9

MRI

Question 10

What does the PROMPT acronym stand for

Answer 10

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

Question 11

What disease should you always test for in anaemia?

Answer 11

Coeliac disease

Question 12

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

Answer 12

Fe deficiency anaemia
Thalassaemia
Pyruvate kinase deficiency

Question 13

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

Answer 13

Asymptomatic patient

Question 14

What are the symptoms of chronic anaemia?

Answer 14

(Exertional) dyspnoea
Fatigue
Signs and symptoms of hyperdynamic circulation

Question 15

What are the signs and symptoms of hyperdynamic circulation?

Answer 15

Bounding pulses
Palpitations
Worsening symptoms if underlying heart/lung disease

Question 16

What is the classification of anaemia by pathophysiology?

Answer 16

Blood loss
Decreased production
Increased destruction

Question 17

What are the causes of blood loss?

Answer 17

GI tract
Urinary
Menstrual loss
Chronic recurrent epistaxis
Hereditary arteriovenous malformation

Question 18

What are the causes of decreased production?

Answer 18

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

Question 19

What are possible symptoms of anaemia due to blood loss?

Answer 19

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

Question 20

What are possible dietary causes of anaemia?

Answer 20

Vegan
Vegetarian
Coeliac
Parasite infection

Question 21

What are some symptoms of bone marrow failure?

Answer 21

Bleeding
Infection
Fevers
Sweats
Weight loss
History of radiation
Prior malignancy

Question 22

What are some symptoms of increased RBC destruction?

Answer 22

Dark urine
Jaundice
Gall stones
Family history of splenectomy
Cholycystectomy

Question 23

What is the classification of anaemia by morphology?

Answer 23

Normochromic normocytic
Microcytic hypochromic
Macrocytic

Question 24

What defines microcytic anaemia?

Answer 24

MCV <80

Question 25

What are possible causes of microcytic anaemia?

Answer 25

Reduced Fe availability Reduced haeme synthesis Reduced globin production

Question 26

What are possible causes of iron deficiency?

Answer 26

Fe deficient diet Malabsorption of Fe Increased Fe requirements Blood loss

Question 27

What can affect haeme synthesis?

Answer 27

Lead poisoning | Acquired/congenital sideroblastic anaemia

Question 28

Define basophilic stippling

Answer 28

Small dots in periphery of RBCs | = ribosomes

Question 29

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

Answer 29

Basophilic stippling

Question 30

What can affect globin production?

Answer 30

Thalassaemias

Question 31

What are the signs of thalassaemia on the blood film?

Answer 31

Hypochromia Microcytosis Target cells Tear drops

Question 32

What do iron studies in iron deficiency anaemia show?

Answer 32

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

Question 33

What do iron studies in anaemia of chronic disease show?

Answer 33

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

Question 34

What do iron studies in thalassaemia show?

Answer 34

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

Question 35

What are the clinical features of iron deficiency anaemia?

Answer 35

``` Fatigue Pallor Exertional dyspnoea Koilonychia Angular cheilosis Glossitis ```

Question 36

What are the causes of hypochromic microcytic anaemia?

Answer 36

``` Fe deficiency Thalassaemia Sickle cell disease Pb poisoning Sideroblastic anaemia ```

Question 37

What are the causes of normochromic normocytic anaemia?

Answer 37

Anaemia of chronic disease Haemolysis Renal failure Pregnancy dilution

Question 38

What are the causes of macrocytic anaemia?

Answer 38

``` B12/folate deficiency Alcoholism Liver disease Drugs Hypothyroidism Myeloma ```

Question 39

What are the investigations for haemolytic anaemia?

Answer 39

``` 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 ```

Question 40

What are the features of intravascular haemolysis?

Answer 40

Blood film fragmentation Haemoglobinaemia Haemosidinuria

Question 41

What are the causes of intravascular haemolysis?

Answer 41

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

Question 42

What are the clinical features of extravascular haemolysis?

Answer 42

Spherocytes Bite cells Sickle cells

Question 43

What are the non-immune causes of extravascular haemolysis?

Answer 43

Hypersplenism Red cell membrane disorders Red cell enzyme disorders

Question 44

What are some immune causes of extravascular haemolysis?

Answer 44

Cold agglutinin disease - IgM | Warm agglutinin disease - IgG

Question 45

How is haemolysis treated?

Answer 45

``` Corticosteroids IVIg Immunosuppression Rituximab Splenectomy Dapsone Anabolic steroids ```

Question 46

What is rituximab?

Answer 46

Anti-CD 20 mAb