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CSI year 2 > Case 13 Tiredness > Flashcards

Case 13 Tiredness Flashcards

1
Q

Who is prone to get anaemia?

In what cases would men and postmenopausal women feel tired due to anaemia?

A

Women with heavy periods and women who are pregnant

the cause is more likely to be problems with the stomach and intestines, such as anulceror takingnon-steroidal anti-inflammatory drugs (NSAIDs).

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2
Q
  • What deficiencies can cause anaemia that leads to tiredness?
A

Iron, Vitamin B12 and Folate

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3
Q
  • An overload of which of these minerals can cause tiredness as well?
A

Iron → Haemochromatosis can lead to tiredness

Haemochromatosis causes pulmonary, pancreatic and hepatic dysfunction, all of which are risk factors for anaemia

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4
Q
  • What is sleep apnoea and how can this cause tiredness?
A

Condition where your throat narrows or closes during sleep and repeatedly interrupts your breathing

This leads to loud snoring and drop in blood oxygen levels so you feel tired next day and you wake up often in the night

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5
Q
  • Who is sleep apnoea most common in?
A

Overweight middle aged men

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6
Q
  • What can exacerbate sleep apnoea?
A

Drinking alcohol - relaxes muscles in throat

Smoking - irritates nose and throat causing swelling here

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7
Q
  • How can an under-active thyroid cause tiredness?
  • What other symptoms may present in an under-active thyroid?
A

Low thyroxine → Tiredness

Low thyroxine → Weight gain, aching muscles and dry skin (reduced eccrine gland secretion)

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8
Q
  • What is coeliac disease?
  • What are other symptoms of coeliac disease?
A

Condition where your immune system attacks your own tissues when you eat gluten

diarrhoea, bloating, anaemia and weight loss

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9
Q
  • What is myalgic encephalomyelitis also known as?
A

Chronic fatigue syndrome

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10
Q
  • What are other symptoms that may present with ME?
A

Muscle or joint pain

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11
Q
  • What are some of the symptoms of type 1 and 2 diabetes?
A

Tiredness

Very thirsty, peeing a lot (perhaps at night), weight loss

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12
Q
  • What is glandular fever and what symptoms does it result in?
  • What category does glandular fever occur commonly in?
A

Common viral infection causing fatigue, along with fever, sore throat and swollen glands

Teenagers and young adults

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13
Q
  • When do symptoms of glandular fever usually clear up?
A

Symptoms usuallyclear up within4 to6 weeks, but the fatigue can linger for several more months

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14
Q
  • How can depression make you feel tired?
A

It can stop you falling asleep or cause you to wake up early in the morning, making you feel more tired during the day

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15
Q
  • What is Restless Legs Syndrome?
A

Overwhelming urge to move your legs, which can keep you up at night

You may also have pins and needles or deep ache in legs

Legs may jerk spontaneously through the night

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16
Q
  • How does RLS cause tiredness?
A

Leads to disrupted sleep and poor sleep quality so you feel very tired throughout the day

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17
Q
  • Does Generalised Anxiety Disorder affect more men or women?
  • How does GAD affect patients?
A

women

They feel worried and irritable and people with GAD often feel tired

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18
Q
  • What are the causes of primary hypothyroidism?
A

Iodine deficiency - lack of Thyroxine production

Hashimoto’s - Antibodies against TSH receptors therefore no TSH effect on thyroid and so lack of thyroxine production

Viral thyroiditis - due to viral infection, hypo-thyr. is the last stage of this infection and occurs whilst body is resolving infection

Congenital - hypoplastic, failure of devel of thyroid gland

Thyroidectomy - lack of follicular cells

Cancer treatments - radiotherapy induced destruction of thyroid gland cells

radioactive iodine treatment , anti thyroid drugs, some medicines eg lithium

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19
Q
  • What are the secondary causes of hypothyroidism?
A

Pituitary adenoma - impaired blood flow to normal tissue/ compression of normal tissue so less TSH secreted

Craniopharyngioma - progressive loss of production of some or all of pituitary hormones such as TSH

Sheehan’s syndrome - ischaemic necrosis of pituitary gland therefore hypopituitarism and lack of TSH secretion

Iron overload - Iron causes injury to thyroid followed by development of anti thyroid antibodies and hypothyroidism

Sarcoidosis - thyroid antibody positive in 20-30% of patients with extensive infiltration by epithelioid granulomas

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20
Q
  • What does the Antigen Presenting Cell mistake for a foreign antigen in Hashimoto’s Hypothyroidism?
A

TPO is picked up as an antigen by Antigen Presenting Cell

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21
Q
  • What does the APC do after it recognises the ‘foreign’ antigen?
A

APC presents MHC II to T cells

22
Q
  • What is the co-stimulation required for the T cell to be activated?
A

APC presents B7 to the T cell’s CD28 as the T cell needs co-stimulation from both the B7 and MHC II

B7 -> CD28

MHC II (on APC) -> TCR

23
Q
  • What is the co-stimulation required by the B cell to become activated?
A

B cell also needs co-stimulation from the T cell’s CD40 onto it’s CD40L. TCR on T cell bind to MHC II on B cell

CD40 (on T cell) -> CD40L
TCR -> MHC II (on B cell)

24
Q
  • What is the resultant product that leads to thyroid damage?
A

Anti-TPO antibodies attack the thyroid gland’s TPO

25
Q
  • Which cells are innate cells in the immune system?
A

Eosinophil, Basophil, Neutrophil, Macrophage, Dendritic cell

26
Q
  • Why do the innate cells not attack host cells?
A

Innate cells → Very fast and so they detect molecular patterns on the cell surface of the host cells such as PAMPs (pathogen associated molecular patterns

Host cells, physiologically do not release these and so there is no attack on them

27
Q
  • What stops the B and T cells from attacking the host cells?
A

B cells and T cells → AIRE expresses many genes in the body so it is possible for the thymus or bone marrow to produce a variety of antigens through mixing combinations of genes which the B and T cells interact with during development and if they are autoimmune then they are destroyed

They are released into the circulation if they did not react with any of the host cell antigens replicated by AIRE

Treg cells are responsible for suppressing this autoimmunity and destroying them

28
Q
  • What stops the Natural Killer cells from attacking the host cells?
A

NK cells → Inhibitory receptor on the NK cell as well as a stimulatory receptor

The stimulatory receptor binds to the stimulatory ligand of the host/foreign cell

The inhibitory receptor binds to the self-MHC I which is present on all nucleated (host) cells

If both receptors are bound, then the NK cell does not react which should be good as all host cells have the MHC I

Foreign cells or abnormal host cells will not usually have self-MHC I and so the NK cell has nothing to inhibit it from killing the cell

29
Q
  • How would you classify the tiredness in fatigue?
A

Tired is subjective

Look at frequency (common-uncommon)

Look at consequence (less serious - very serious)

Assessment of fatigue on best practice BMJ

30
Q
  • What are 3 types of tiredness?
A

Drowsiness

Shortness of breath

Weakness

31
Q
  • What are some of the red flag symptoms associated with tiredness?
A

Specific malignancy features - focus on lung, breast, colon, upper GI and gynae

Weight loss - Thyroid, Coeliac disease

Infective symptoms - TB, Glandular fever, Lyme

Lymphadenopathy

Focal neurology - stroke

Joint pains - rheumatoid arthritis

32
Q
  • What are the minimum requirements in the examination of a patient who presents with tiredness?
A

Pulse

Blood pressure

BMI

33
Q
  • What are the initial bloods taken for tiredness?
A

FBC - not just for anaemia but also iron deficiency and haematological malignancy

Lymphomas can have a normal Total WCC with an abnormal differential in early stage, later could be low RBC, WCC, platelets

Thyroid function

ESR

Glucose - diabetes mellitus

34
Q
  • Treating what for anaemic menstruating women can improve symptoms of tiredness for them?
A

Low ferritin

35
Q
  • What are the side effects of treatment of hypothyroidism and how can patients cope with them?
A

If too high dose - atrial fibrillation or bones may get too thin

Weight gain or loss, headache, vomiting, diarrhoea, changes in appetite, fever, changes in menstrual cycle, sensitivity to heat (hyperthyroid symptoms)

Talk to GP to lower the dose

36
Q
  • Should patients with an under active thyroid change what they eat?
A

Eat at least 5 portions of a variety of fruit and veg every day

Base meals on higher fibre starchy foods like potatoes, bread, rice or pasta

Have some dairy or dairy alternatives

Eat some beans, pulses, fish, eggs, meat and other protein

37
Q
  • How will the treatment be managed if a female patient wished to get pregnant?
A

Consult GP as soon as they know they are pregnant or wish to try and get pregnant

Have a blood test before conceiving

If already taking levothyroxine, it is recommended that the dosage is increased immediately by 25-50mcg daily

Arrange to have TFT asap

Even if TFT isn’t ideal at start of pregnancy, as long as levothyroxine has been increased, the chance of complications of pregnancy occurring are only slightly higher and a normal pregnancy is likely

38
Q
  • How is hypothyroidism diagnosed?
  • What factors may affect these tests unexpectedly?
A

TFT - high TSH, low T4

Thyroid antibody screen

Medications the patient is on
Common illnesses that can alter the blood test readings temporarily

39
Q
  • What is mild thyroid failure or sub clinical hypothyroidism?
  • What would the levels of TSH and T4 be for mild thyroid failure or sub clinical hypothyroidism?
  • If a patient has this, what must be done?
A

Slight hypothyroidism that no obvious symptoms are seen and can only be detected by blood tests

Slightly high TSH, normal T4

Regular TFT and consult doctor if notice of any symptoms as they may benefit from treatment

40
Q
  • What is the initial dose of Levothyroxine dependent on?
  • What dose do most patients require?
A

Patient’s weight and blood test results

100-150mcg per day
Can be lower than 75 or above 300mcg depending on needs

41
Q
  • When in the day should Levothyroxine be taken?
A

In the morning with water, on an empty stomach at least half hour before eating and drinking anything

42
Q
  • How far from taking Ca2+, Fe2+, cholesterol-lowering drugs and multivitamin tablets should Levothyroxine be taken?
A

4 hours as these can reduce absorption

43
Q
  • What increases absorption of levothyroxine and how?
A

Grapefruit as it increases acidity of the stomach

44
Q
  • Is Levothyroxine given when both symptomatic and asymptomatic under active thyroid is present?
A

Yes as long as low T4 is shown in TFT to stop symptoms appearing or progressing

If mild hypothyroidism → TFT until shows low T4 or until symptomatic

45
Q
  • Why might TSH be normal or even low when there is low T4?
A

Down-grading of the hypothalamic-pituitary axis due to a state of hypo-metabolism that the low thyroid function induces

The hypothalamus responds poorly to low T4 in blood and may not produce normal level of TRH which then does not produce the normal level of TSH

The TSH receptors on the thyroid gland may be damaged anyways so chain reaction of failure as T4 production cannot be initiated

46
Q
  • Describe the mechanism occurring in Goitrous Autoimmune Thyroiditis?
A

Progressive infiltration of white cells enlarges thyroid and in the gland becomes a mass of fibrous tissue with the follicular cells disappearing so there is no place for T4 to be made

The gland becomes enlarged into a goitre and sometimes the fibrous tissue takes over completely

47
Q
  • What occurs in Atrophic Autoimmune Thyroiditis?
A

Results in thyroid gland shrinking with progressive loss of tissue

Antibodies block the TSH receptors in the thyroid and so the glandular tissue shrinks

48
Q
  • Causes of tiredness
A

Anaemia

Sleep apnoea

Underactive thyroid

Coeliac disease

Chronic fatigue syndrome

Diabetes

Glandular fever

Depression

Restless legs syndrome

Anxiety

49
Q
  • Possible tests to diagnose fatigue and what they do
A

FBC- anaemia (low RBC, low Hb) and Haematological abnormalities

U&E- CKD (abnormality in Na+, K+, HCO3-, urea, creatinine, glucose)

Vitamin D

TFT

HBA1c

C-reactive protein- inflammatory conditions

Coeliac screen

autoimmune screen

EBV serology- for glandular fever

50
Q

Give examples of PAMPs

A

peptidoglycans, lipopolysaccharides, lipoteichoic acid, mannans, flagella proteins

CSI year 2 (8 decks)

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