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CSI > Case 12- Tiredness > Flashcards

Case 12- Tiredness Flashcards

1
Q

what is the difference between tiredness and fatigue

A

Tiredness can be relieved by sleep and rest

Fatigue- this is when tiredness is overwhelming and is not relieved by sleep and rest

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2
Q

According to the NHS website, what are the 10 medical reasons that can make you extremely tired?

A
  • Anxiety
  • Aneamia
  • Restless legs
  • Depression
  • Glandular fever
  • Diabetes
  • Chronic fatigue syndrome
  • Coeliac disease
  • Hypethyroidism
  • Sleep Apnoea
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3
Q

Anaemia- what type of anaemia is more common in causing tiredness? and who does it affect most?

A

Iron deficeincy anaemia

It normally occurs in women with heavy periods or pregnant woman- they are prone to aneamia

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4
Q

What type of anaemia can mostly occur in men and postmenopausal women. Explain your reasoning

A

The problem is more likely to be with the stomach and intestines such as ulcers or taking NSAIDs

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5
Q

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?

A

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

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6
Q

Describe the features of sleep apnoea and how it can cause tiredness

A

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

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7
Q

Describe the features of hypothyroidism and how it can make you tried

A

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

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8
Q

Describe the features of coeliac disease and explain how it can make you tired

A

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

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9
Q

Describe the features of chronic fatigue syndrome

A

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

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10
Q

Describe the features of glandular fever.

A

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

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11
Q

How can depression make you tired?

A

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

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12
Q

Describe the features of restless leg syndrome and explain how it can cause tiredness

A

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

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13
Q

Describe the features of anxiety and explain how it can make you tired

A

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

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14
Q

Describe the general epidemiology of tiredness (from Youtube video)

A

75% of tiredness symptoms resolve within a month and 2/3 of them are from a result of life stressors

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15
Q

What are the different types of tiredness? which one should you be more concerned about?

A
  • 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

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16
Q

When a pt present with triedness what should you do?

only 1 in 400 do

A

Explore HPC by accessing 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

Mnagement of persistent unexplained tiredness with normal inital bloods

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17
Q

What red flags should you screen for, if a pt presents with tiredness?

A
  • Lymphadenopathy
  • weight loss
  • Joint pains
  • Focal neurology
  • Specific malignancy feature- focus on breast, lung, colon, upper GI and gynae
  • Ineffective symptoms - TB, glandular fever and lyme
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18
Q

What are the inital bloods you should investigate for tiredness

A
  • 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

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19
Q

What are the potential causes of hypothyroidism?

A

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

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20
Q

Whata re the sympotms of hypothyroidism?

A

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
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21
Q

How is hypothyroidism diagnosed

What are the caveats?

A

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

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22
Q

What is mild thyroid failure or subclinical hypothyroidism

A

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

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23
Q

What is the treatment procedure for hypothyroidism

A

Levothyroxine- negligible side effects at correct dose. Dose adjusted using TSH levels AND body weight

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

24
Q

normally the T4 dose is increased graudually. However in some pts the doctors are extra cautious, what demographic of pts are these?

A

Severe hypothyroidism or having risk of heart problems

25
Q

What advice must you give pts taking levothyroxine to maximise health outcomes

A

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

26
Q

What substance is known to increase absoprtion of Levothyroxine? explain your reasoning

A

grapefruit

it increases acidity of the stomach hence levothyroxine has a low pKa

27
Q

it’s easy to miss a dose. explain why and give what advice shoud you give pt regarding this

A

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

28
Q

what condition will mmake LT4 deteriorate ?

A

when subjected to extreme temperatures

29
Q

what is the correct dose of LT4?

Why should you beware of giving too much LT4

A

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 etc

30
Q

Some pts still complain of symptoms despite TSH levels in the reference range. what should you do?

A

Refer to endocrinologist which may give combination of T3 and LT4 (it may help). However LT3 isnt always under the NHS

31
Q

How can the brand of LT4 affect pts

A

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

32
Q

how do you manage pregnancy with hypothyroidism

A

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

33
Q

Who normally takes care of pts with hypothyroidsim

A

GP, but can be referred to endocrinologist if there are problems

34
Q

what is the level of TSH that requries treatment for sub-clinical hypothyroidism

any exceptions?

A

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
35
Q

What is Hashimoto’s Thyroiditis

A

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.

36
Q

How can you clinically detect Hashimoto’s ?

When can it be missed in diagnosis

A

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

37
Q

In sub-clinical hypothyroidism, when can the antibody levels diminish?

A

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

38
Q

Why is it that sometimes when T4 descreases, TSH doesn’t rise accordingly

A

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

39
Q

How can you tell there’s autoimmune process at work even if T4 or TSH is normal

A

Presence of antibodies

40
Q

What are the clinical features you can find in pts with autoimmiune thyroiditis

A

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 becomes evident and it can show itself in 2 ways we can PICK out :

  1. Goitrous Autoimmune Thyroiditis- the version Hashimoto first described
  2. Atrophic Autoimmune Thyroiditis - MOST COMMON FORM
41
Q

What happens in Atrophic Autoimmune thyroditis

A

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.

42
Q

What happens in Goitrous Autoimmune Thyroiditis

A

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.

43
Q

What percentage of pt wiht fatigue recieve a diagnosis

A

66%

44
Q

What percentage of pts with fatgue recieve a diagnosis via blood tests

A

10@ or less

Hence History is very important in diagnosis.

45
Q

What are the very important concepts when considering differential diagnosis

A

Consider the common ones first before the rare.

Be careful not to miss anyone with rare consequences.

46
Q

What are the differential diagnosis for Mina?

A

The 10 causes in the NHS webite and:

  • Addison
  • Vit D deficiency
  • Heart failure
  • Infection
  • Lupus
  • Cancer
  • pregnancy
  • GH/ACTH def
  • Drug side effects
47
Q

Sometimes test results come back negative. What can you do to preserve the doctor/pt relationship

A

You need to manage expectations (before tests) of the pt and explain that sometimes tests are negative.

48
Q

what extra questions were asked to narrow the differential diagnosis for Mina. What was less likely after the questions

A

less likely:

  • Sleep apnoea
  • Glandular fever
  • Lupus
  • Pregnancy
49
Q

Due to your top 2 differentials:

What 5 tests were most likely to be ordered for Mina. Explain your reasoning

A
  • 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

50
Q

Draw the thyroid axis

A
51
Q

What’s the importance of checking for CRP

A

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.

52
Q

Draw the pathways for how the immune system attack the thyroid in Hashimoto’s Thyroiditis

A
53
Q

What were the signifcant resutls from the tests mina had?

A

TSH- high

Free T3/T4- low

54
Q

What are the symptoms of hypothyroidism

A
55
Q

Why don’t the Immune system attack host cells

A

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
  • lipo;echoic acid

NK cell attack cells WITHOUT MHC 1

56
Q

how would you explain autoimmune to Mina?

A

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.

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