Constitutional DDx

Question 1

What are the main things to do in a tiredness history?

Answer 1

CLARIFY - poor sleep or general lethargy
The key with tiredness is SYSTEMS review
move on from presenting complaint/ODP because tiredness is not a dx you need to narrow it down asap
Ask:
Constitutional –> this screens for infections and B symptoms
Weight loss = alarm bells
Ask about drugs!

Question 2

What should you do in a constitutional history?

Answer 2

In any constitutional history ask about the others - 
pain
tiredness
fever
appetite
weight loss

Question 3

What systems may be impacted in a tired patient?

Answer 3

CVS (heart failure, infective endocarditis)
Respiratory (lung cancer, tuberculosis)
GI (bowel cancer, coeliac disease)
Liver (viral hepatitis, chronic liver disease)
Neuro (myasthenia gravis, Motor neurone disease)
Endo (thypothyroidism, hypopituitarism, pituitary adenoma, addisons disease, diabetes)
Renal (CKD)
Rheumatological (RA, SLE)
haematological (anaemia from any cause, leukaemia/lymphoma)
GU (HIV, STIs)
urological (prostate/bladder cancer)
Gynaecological (menorrhagia)
psychiatric (depression)
others (drug use, chronic fatigue, poor sleep hygeine, benzos, crash dieting)

Question 4

What conditions may present with tiredness?

Answer 4

Anaemia
Thyroid
Cancer
Cardiac, renal or liver failure
Diabetes
Infection
Depression
Chronic fatigue/ME
Environmental

Question 5

What is the presentation of anaemia?

Answer 5

Tiredness
SOBOE
chest pain
palpitations
confusion
--> non-specific hypoxia signs

Question 6

What would be found on examination and history of anaemia?

Answer 6

Blood loss - menorrhagia, NSAIDs, peptic ulcers, CRCs, UC
decreased production (see Ix and findings)

in all anaemia = pallor
IDA - koilonychia, atrophic glossitis, angular stomatitis
B12 - glossitis, neuro symptoms,
folate - mouth sores, glossitis, poor growth in kids, vascular disease

In B12 - neurologic symptoms, in folate = none

Question 7

What would Ix findings for anaemia show?

Answer 7

Do FBC, iron studies, B12 and folate and blood smear:

microcytic anaemia e.g. reduced MCV could be iron def (haem deficiency), thalassamia trait (globin deficiency), anaemia of chronic disease (late), lead, sideroblastic anaemia

Normocytic anaemia- normal MCV, normal RBC
Anaemia of chronic disease “early”, bone marrow hyperplasia, Chronic renal failure = low epo

Macrocytic, increased MCV: B12 or folate deficiency, myelodysplasia, drug induced (methotrex), liver disease/alcohol, hypothyroidism, smoking

Question 8

What would other presenting features of thyroid be in a tiredness history?

Answer 8

Can be in both hyper (burnout) and hypo thyroid

Usually tired in hypo - cold intolerance, menorrhagia, constipation, weight gain, proximal weakness

Question 9

What would the examination and history of thyroid problems in a tiredness history reveal?

Answer 9

Hypothyroid:
Goitre
periorbital oedema
bradycardia
carpal tunnel
proximal weakness
depression 
delayed tendon reflexes

Question 10

What Ix should be done if you suspect thyroid alterations as a cause of tiredness?

Answer 10

Thyroid function tests

Question 11

What would the other presenting features of cancer presenting intially as tiredness be?

Answer 11

cancer could be anywhere
if bone pain is implied then think mets
common ones to metastatise to bone = BLT + KetchuP
The big 4 cancers are Breast, Prostate, Lung and Colorectal.

Question 12

What would the examination and history of cancer presenting initially as tired be?

Answer 12

B symptoms - fever, night sweats, weight loss, ask about appetite

Ask about risk factors - smoking,

• alcohol,
• drugs,
• OCCUPATION,
• FHx
• PMH

consider the demographic of the person infront of you - think cervical cancer if younger etc

Question 13

What would the Ix of cancer presenting initially as tired be?

Answer 13

LFTs - (ALP-bone mets; no raised GGT)
Ca, phosphate (always request PTH with these)
Specific cancer markers:
Ovarian - CA125
Pancreatic - CA19-9
CRC - CEA
breast - CA15.3
Thyroid - Tg (released from follicle cells & stored for when needed to breakdown into T3 and T4)
Prostate - PSA

CXR if suspect lung cancer

refer on for specialist management

Question 14

What would the presentation of cardiac, renal or liver failure presenting initially as tired be?
What would be seen on Hx and exam?
What investigations should be done?

Answer 14

Co existing signs of their diseases!
Ankle oedema
Pmhx of cardiac, renal or liver disease likely to be present
Cardiac = BNP
Renal = U&E
Liver = LFTs

Question 15

What would the presentation of diabetes presenting initially as tiredness be?

Answer 15

increased urination
increased thirst
increased appetite
weight loss
More likely to see T1 - young adolescent presents for the first time or havent taken their insulin
?med changes
T2 may present with tiredness but usually asymptomatic

Question 16

What Hx/signs of diabetes presenting initially as tiredness be?

Answer 16

if DKA - abdo pain, kussmaul breathing, pear drop breath

Question 17

What Ix would you do for diabetes presenting initally as tiredness?

Answer 17

Urine dipstick - ketones, important to rule out DKA
BM - blood glucose (on the spot but also do send a blood sample)
C-peptide (urine, see how much insulin is being made)

DMT2 - fasting plasma glucose and HBA1C. Say that you may need to repeat again 2 weeks later.
Urine dip - prove theres glucose in the urine, not diagnostic

Question 18

What would the presentation of infection presenting initially as tiredness be?
What signs maybe seen?

Answer 18

Depends on the infection!
Viral will obviously be the most common. Short history flu-like symptoms. Stop and think that it may be chronic fatigue syndrome – Myalgic encephalomyelitis due to a prolonged post-viral state of fatigue.

EBV – young M/F, risky sexual activity. Sore throat, pyrexia, lymphadenopathy = classic triad.
EBV signs: splenomegaly, palatal petechiae, hepatomegaly

Question 19

What Ix should be done if infection is suspected in a tiredness presenting complaint?

Answer 19

EBV = monospot test and FBC w/Differential (lymphocytosis)

TB = CXR, Stain of Respiratory aspirates (from bronchoalveolar lavage on bronchoscopy). rapid dianostic nucleic acid amplification tests. Contact CCDC and contact trace.

Also always do a HIV test if you suspect TB.

HIV may also present with tiredness/flu-ey like illness (seroconversion)

Question 20

What would the presentation of depression presenting initially as tiredness be?

Answer 20

Core signs and symptoms: low mood, anhedonia for >2weeks

Question 21

What would examination and history of someone with depression initially presenting as tiredness reveal?

Answer 21

Sleep disturbance
early morning waking
[>2 hours earlier than usual]
decreased appetite
weight loss

Question 22

What Ix would you do for someone with depression initially presenting as tiredness?

Answer 22

Mood screen
during the last month have you often been bothered by:
feeling down, depressed or hopeless?
had little interest or pleasure in doing things?
if yes… full assessment for depression: or at least state you would like to bring the patient back to do this

Question 23

What would the presentation of chronic fatigue/ myalgic encephalomyelitis (ME) presenting initially as tiredness be?

Answer 23

Persistent fatigue for more than 6 months
in a previously healthy individual- not due to ongoing physical exertion,
not relieved by rest and cannot be explained by another medical condition

Question 24

What would the history/exam of chronic fatigue/ myalgic encephalomyelitis (ME) depression presenting initially as tiredness be?

Answer 24

myalgia
headaches
sore throat
poor concentration and memory
possible past history IBS and or fibromyalgia
NB: fatigue is also a predominant symptoms of fibromyalgia but less dominant than MSK pain

Question 25

What would the investigations of chronic fatigue/ myalgic encephalomyelitis (ME) depression presenting initially as tiredness be?

Answer 25

Its a clinical diagnosis
explore PMH further
invite them back to explain and discuss diagnosis and impact at a later date

Question 26

What are the clues of environmental impacts for tiredness as a presenting complaint?
What are the investigations?

Answer 26

The major cause is poor sleeping
environment/unstructured sleeping routine
works long hours w/burn out
Has small children?
Is a carer?
+/- anxiety or depression
may have some drug dependencies e.g. alcohol, smoking, benzo use
Take a detailed social history
suggest some lifestyle changes like mindfulness
treat any underlying psychological disorders and do a proper MSE (mental state examination) if suspecting them
offer advice about their workers rights

Question 27

What are the key parts of information dealing with PUO?

Answer 27

PUO (fever) = temperature over 38.3 for longer than 3w with no obvious source despite investigation

1) infection
2) malignancy
3) inflammatory/rheumatology
4) misc (drugs, PE, IBD)
5) occupational

ICE them at the start - they may tell you something important
Also ask occupation
Systems review will be incredibly important - cast the net wide dont forget ENT, dental, skin, lumps. Ask about recent illness. Drugs. social including travel. Sexual history if pertinent.
In terms of tests - always say you’ll measure the temperature
appropriate Ix with your running diagnosis
think other demographics as well e.g. age, smoking, occupation