Case 12- Tiredness Flashcards
what is the difference between tiredness and fatigue
Tiredness can be relieved by sleep and rest
Fatigue- this is when tiredness is overwhelming and is not relieved by sleep and rest
According to the NHS website, what are the 10 medical reasons that can make you extremely tired?
- Anxiety
- Aneamia
- Restless legs
- Depression
- Glandular fever
- Diabetes
- Chronic fatigue syndrome
- Coeliac disease
- Hypothyroidism
- Sleep Apnoea
Anaemia- what type of anaemia is more common in causing tiredness? and who does it affect most?
Iron deficeincy anaemia
It normally occurs in women with heavy periods or pregnant woman- they are prone to aneamia
What type of anaemia can mostly occur in men and postmenopausal women. Explain your reasoning
The problem is more likely to be with the stomach and intestines such as ulcers or taking NSAIDs
Explain hwo the tiredness for anaemia feels and what’s the name of the condition that causes iron overload and what demogrpahic does it affect?
Typically, you feel you can’t be bothered to do anything, your muscles feel heavy, and you get tired very quickly.
Haemochromatosis- can cause tiredness. Inherited condition that affects men and women between ages of 30 and 60
Describe the features of sleep apnoea and how it can cause tiredness
Throat narrows or closes during sleep and repeatedly interrupts breathing.
leads to loud snoring and hypoxia. This makes you wake up often at night and then you’re exhausted the next day.
most common in overweight middle aged men. Drinking alcohol and smoking exercebates it
Describe the features of hypothyroidism and how it can make you tried
underactive thyroid gland- makes you tired
You put on wieght and have aching muscles and dry skin. Most common in women especially as they get older
Describe the features of coeliac disease and explain how it can make you tired
Lifelong disease when immune system reacts to gluten (found in bread, cakes etc).
1% of people in UK are affected but many don’t know they have the disease
other symptoms of coeliac disease apart from tiredness are:
- diarrhoea
- bloating
- anaemia
- weight loss
Blood test fro specifc antibody can confirm this
Describe the features of chronic fatigue syndrome
Also known as myalgic encephalomyelitis.
This is a sever and disabling fatigue that goes on for atleast 4 months.
Other symptoms may present such as: msucle or joint pain
Describe the features of glandular fever.
Common viral infection that causes fatigue alongside fever, sore throat and swollen glands.
mostly occurs in teenagers and young adults. Symptoms usually clear up within 4-6 weeks but fatigue can linger for several more months
How can depression make you tired?
Makes you feel drained of energy and also stop you from falling asleep.
It can also keep you awake at night; this makes you more tired during the day
Describe the features of restless leg syndrome and explain how it can cause tiredness
Overwhelming urge to move legs which can keep you awake at night.
You can also get unpleasant crawling sensation or deep aches in the legs. Your legs might jerk spontaneously during the night
All these symptoms disturbs quality and quantity of sleep
Describe the features of anxiety and explain how it can make you tired
Feeling anxious sometimes is normal but some people have too much anxiety as it affects their daily life
This is generlaised anxiety disorder; affects women slightly more than men.
This can make you feel tired, worried and irritable
Describe the general epidemiology of tiredness (from Youtube video)
75% of tiredness symptoms resolve within a month and 2/3 of them are from a result of life stressors
What are the different types of tiredness? which one should you be more concerned about?
- Drowsiness
- shortness of breath
- weakness
exertional tiredness is more likely to be physical.
Be concerned if someone wakes up ok but tiredness gets worse as they do things
When a pt present with triedness what should you do?
Explore why the patient presented by assessing type of tiredness and how it functionally affects them
Screen for red flags
Explore any psychosocial triggers by asking exploring social history - look at mood, alcohol, money, family etc
Examine the pt- must be minimum HR, BP AND BMI.
Make a plan- investigations
Management of persistent unexplained tiredness with normal inital bloods
What red flags should you screen for, if a pt presents with tiredness?
- Lymphadenopathy
- weight loss
- Joint pains
- Focal neurology
- Specific malignancy feature- focus on breast, lung, colon, upper GI and gynae
- Infective symptoms - TB, glandular fever and lyme
What are the inital bloods you should investigate for tiredness
- FBC- anaemia, iron def or othe blood malignancy
- Thyroid function
- ESR
- Glucose
Even in non-aneamic menstruating women, treating with low ferritn can improve tiredness symptoms
What are the potential causes of hypothyroidism?
Autoimmune thyroid disease- Most common is Hashimoto’s thyroiditis.
Congenital (rare)
Radioiodine treatment or surgery fro an overactive thyroid
Antithyroid drugs
Meds such as lithium ( for mental health problems) and Amlodarone (some heart problems).
Some health foods in EXCESS like kelp/seaweed
Cough meds with large amounts of iodine
Hypopituitarism
Radiation for head and neck cancers
Whata re the sympotms of hypothyroidism?
Everything both physical and mental slows down, hence symptoms like:
- Fatigue and tiredness
- Increased awareness of the cold
- Dry and coarse skin
- Dry and thinning hair
- Hoarse or croaky voice
- Muscle weakness, cramps and aches
-Puffy face and bags under the eyes
-Pins and needles in the fingers and hands (carpal tunnel syndrome)
- Slow speech, movements and thoughts
- Low mood or depression
- Memory problems
- Difficulty in concentration
- Constipation
- Irregular periods
- Slow heart beat
- Slightly raised blood pressure
- Raised cholesterol
- Slowed growth (in children)
How is hypothyroidism diagnosed
What are the caveats?
Thyroid function test- high TSH and low fT4. this is a sign of 1y hypothyroidism.
There are also thyroid antibodies test (e.g for TPO antibody) to confirm the cause is autoimmunity
However, common illnesses can affect blood readings temporalily and over the counter or prescribed meds can affect results so tell your doctor about any meds your taking
What is mild thyroid failure or subclinical hypothyroidism
Hypothyroidism is very slgiht hence No obvious symptoms
Only be detected by blood test (raised TSH above 10mU/L). However fT4 is normal
Sometimes can be discovered by blood results of another automimmune disorder or because of hsitory of thyroid disorders in family.
Get a thyroid function test and you may benefit from treatment
What is the treatment procedure for hypothyroidism
Levothyroxine- negligible side effects at correct dose. Dose adjusted using TSH levels AND body weight.
We aim for TSH to be in lower part of reference range and fT4 to be above middle reference range.
Dose varies normally from 100-150mcg. But can go up and down.
It takes several months for you to get back to normal and you will have regular blood tests every 6-8 weeks and T4 dose can be adjuisted accordingly.
After blood results are stable with no more symptoms then you take blood tests annually
normally the T4 dose is increased graudually. However in some pts the doctors are extra cautious, what demographic of pts are these?
Severe hypothyroidism or having risk of heart problems
What advice must you give pts taking levothyroxine to maximise health outcomes
Take early in the morning atleast 30 min before eating or drinking anything.
Take it EVERYDAY. Try not to miss a day as this could affect blood results, Take it even of opther illness develops
Take 4 hours apart from calcium, iron, cholesterol lowering drugs and multivitamin tablets- they reduce absorption.
check with your doctor if you’re on any medication
You must take it for the rest of your life
What substance is known to increase absoprtion of Levothyroxine? explain your reasoning
grapefruit
it increases acidity of the stomach hence levothyroxine has a low pKa
it’s easy to miss a dose. explain why and give what advice shoud you give pt regarding this
Since body stores large amount of T4 then you won’t notice when you miss a dose.
Devise a system to take it everyday as missed doses can affect health and blood results
what condition will mmake LT4 deteriorate ?
when subjected to extreme temperatures
what is the correct dose of LT4?
Why should you beware of giving too much LT4
Depends on pts symptoms;’ lowest possible that alleviate all symptoms.
However, this correlates with TSH in lower reference range and fT4 in higher or slightly above reference ranges
Too much LT4 can cause symptoms of hyperthyroidism e.g palpitations and thin bones
Some pts still complain of symptoms despite TSH levels in the reference range. what should you do?
Refer to endocrinologist which may give combination of tr-iodothyronine (LT3) and levothyroxine (LT4) (it may help). However LT3 isnt always under the NHS
How can the brand of LT4 affect pts
Very rarely, pts feel quite unwell with one brand compared to the other.
This could be due to differecnes in fillers and bulking agents between brands.
ask your doctor and they can prescribe you a particular brand
how do you manage pregnancy with hypothyroidism
As soon as pt is pregnant, LT4 dose should be increased immediately by 25-50mcg.
TSH levels should be measured every 6 weeks
Arrange thyroid function test immediately. Even though your fT4 levels isn’t ideal at the start of pregnancy, pregnancy complications is only slightly higher than normal
Succerssful pregnancy is still very likely. After pregnancy, fT4 levels should be normalised again
Who normally takes care of pts with hypothyroidsim
GP, but can be referred to endocrinologist if there are problems
what is the level of TSH that requries treatment for sub-clinical hypothyroidism
any exceptions?
if TSH is more than 10mU/L
This is becasue there’’s a higher risk of crornary heart diseas and mortality in pt with this TSH levels. Also progression risk to hypothyroidism is very high
Exceptions for below 10mU/L:
- Pregnant women with TPOAb positive and above pregancy range TSH
- Women trying to conceive or history with infertility
- Adults younger than 70, with goitre or TPOAb positive
What is Hashimoto’s Thyroiditis
Form of autoimmune thyroidits (should be called chronic immune thyroditis )
Can be tirggered by stress factors and pregancy. There’s some genetic disposition to having it.
It can involve lymphocytic infiltration, increased ig within gland and raised thyroid antibodies
Hence can cause thyroid to enlarge (NOT ALWAYS) and may start with overactive phase before becoming underactive.
How can you clinically detect Hashimoto’s ?
When can it be missed in diagnosis
Presence of antibodies, raised TSH and low fT4.
Hence missed due to too much reliance on blood tests. This could occur because sometimes when T4/T3 is low the TSH doesn’t rise
In sub-clinical hypothyroidism, when can the antibody levels diminish?
It is worth noting that the antibody levels may diminish as hypothyroidism becomes established, or where treatment with thyroxine is given
Sub-clinical is when TSH rises but fT4 stays normal
Why is it that sometimes when T4 descreases, TSH doesn’t rise accordingly
Maybe a downgrading of the hypothalamic-pituitary axis due to state of hypo-metabolism (CAUSED BY low fT4)
Hence hypothalamus may not produce enough TRH
Also the pituitary may be affected as they may not respond well to thw TRH and hence can’t make enough TSH
Thirdly, the thyroid itself been damaged may be less responsive to TSH anyway
How can you tell there’s autoimmune process at work even if T4 or TSH is normal
Presence of antibodies
What are the clinical features you can find in pts with autoimmiune thyroiditis
Firstly, there coul;d be nothing to show at all and may be found accidentally in blood work for other things
Sooner or later hypothyroidism (hashimoto’s thyroditis) becomes evident and it can show itself in 2 ways we can PICK out :
- Goitrous Autoimmune Thyroiditis
- Atrophic Autoimmune Thyroiditis - MOST COMMON FORM
What happens in Atrophic Autoimmune thyroditis
it results in the thyroid gland shrinking with progressive loss of tissue.
The antibodies block the TSH receptors in the thyroid and on the basis that what you don’t use, you lose, the glandular tissue shrinks.
What happens in Goitrous Autoimmune Thyroiditis
In addition to the white cells taking over the glandular tissue, the gland itself becomes a mass of fibrous tissue, with the follicular cells disappearing.
The gland itself becomes enlarged into a goitre.
Sometimes the fibrous tissue takes over completely.
It has been found also that an increase in dietary iodine has a tendency to worsen autoimmune thyroiditis.
What percentage of pt wiht fatigue recieve a diagnosis
66%
What percentage of pts with fatgue recieve a diagnosis via blood tests
10@ or less
Hence History is very important in diagnosis.
What are the very important concepts when considering differential diagnosis
Consider the common ones first before the rare.
Be careful not to miss anyone with rare consequences.
What are the differential diagnosis for Mina?
The 10 causes in the NHS webite and:
- Addison
- Vit D deficiency
- Heart failure
- Infection
- Lupus
- Cancer
- pregnancy
- GH/ACTH def
- Drug side effects
Sometimes test results come back negative. What can you do to preserve the doctor/pt relationship
You need to manage expectations (before tests) of the pt and explain that sometimes tests are negative.
what extra questions were asked to narrow the differential diagnosis for Mina. What was less likely after the questions
less likely:
- Sleep apnoea
- Glandular fever
- Lupus
- Pregnancy
Due to your top 2 differentials:
What 5 tests were most likely to be ordered for Mina. Explain your reasoning
- FBC- ,many drugs affect this so need baseline (look for anaemia)
- Thyroid function test- top diagnosis was hypothyroidism
- Vit D- family history of this
- HbA1c
- U&Es -
Always link the blood tests you order to your top 3 diagnosis. Don’t be too wasteful
Draw the thyroid axis
What’s the importance of checking for CRP
CRP is a bigger tool than any autoimmune screen. CRP is very sensitive and will pick up any latent infection or inflammation. CRP could be the 4th test.
Draw the pathways for how the immune system attack the thyroid in Hashimoto’s Thyroiditis
What were the signifcant resutls from the tests mina had?
TSH- high
Free T3/T4- low
What are the symptoms of hypothyroidism
Why don’t the Immune system attack host cells
There’s immune tolerance as B cells and T cells develop (AIRE)
Macrophages and granulocytes -They have PAMPS that only detect foreign objects:
The PAMPS attack:
- Peptidoglycan
- LPS
- Manan
- flagella proteins
- lipoteichoic acid
NK cell attack cells WITHOUT MHC 1
how would you explain autoimmune to Mina?
Thyroxine helps to control how fast your body makes and uses energy from food. Your doctor can tell if you have low levels of thyroxine with a blood test.
If your thyroid stops making enough hormones it’s usually because it has been damaged by your immune system.
You’re more likely to get this type of hypothyroidism if someone in your family has it.
How many patients who experience tiredness report it to a GP?
only 1 in 400 do
What other type of anaemia can cause tiredness?
Vitamin B12 or folate deficiency anaemia
What questions might a patient with an underactive thyroid ask their doctor?
Why did I get an underactive thyroid?
Will I get better?
Do I need treatment?
What’s the best treatment for me?
Will I need to have treatment for the rest of my life?
What are the side effects of treatment?
How can I cope with them?
Should I change what I eat?
What are the chances that someone else in my family will get an underactive thyroid?
Does it run in families?
How will my treatment be managed if I wish to get pregnant (women)?
