Constitutional DDx Flashcards
What are the main things to do in a tiredness history?
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!
What should you do in a constitutional history?
In any constitutional history ask about the others - pain tiredness fever appetite weight loss
What systems may be impacted in a tired patient?
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)
What conditions may present with tiredness?
Anaemia Thyroid Cancer Cardiac, renal or liver failure Diabetes Infection Depression Chronic fatigue/ME Environmental
What is the presentation of anaemia?
Tiredness SOBOE chest pain palpitations confusion --> non-specific hypoxia signs
What would be found on examination and history of anaemia?
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
What would Ix findings for anaemia show?
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
What would other presenting features of thyroid be in a tiredness history?
Can be in both hyper (burnout) and hypo thyroid
Usually tired in hypo - cold intolerance, menorrhagia, constipation, weight gain, proximal weakness
What would the examination and history of thyroid problems in a tiredness history reveal?
Hypothyroid: Goitre periorbital oedema bradycardia carpal tunnel proximal weakness depression delayed tendon reflexes
What Ix should be done if you suspect thyroid alterations as a cause of tiredness?
Thyroid function tests
What would the other presenting features of cancer presenting intially as tiredness be?
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.
What would the examination and history of cancer presenting initially as tired be?
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
What would the Ix of cancer presenting initially as tired be?
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
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?
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
What would the presentation of diabetes presenting initially as tiredness be?
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
What Hx/signs of diabetes presenting initially as tiredness be?
if DKA - abdo pain, kussmaul breathing, pear drop breath
What Ix would you do for diabetes presenting initally as tiredness?
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
What would the presentation of infection presenting initially as tiredness be?
What signs maybe seen?
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
What Ix should be done if infection is suspected in a tiredness presenting complaint?
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)
What would the presentation of depression presenting initially as tiredness be?
Core signs and symptoms: low mood, anhedonia for >2weeks
What would examination and history of someone with depression initially presenting as tiredness reveal?
Sleep disturbance early morning waking [>2 hours earlier than usual] decreased appetite weight loss
What Ix would you do for someone with depression initially presenting as tiredness?
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
What would the presentation of chronic fatigue/ myalgic encephalomyelitis (ME) presenting initially as tiredness be?
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
What would the history/exam of chronic fatigue/ myalgic encephalomyelitis (ME) depression presenting initially as tiredness be?
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
What would the investigations of chronic fatigue/ myalgic encephalomyelitis (ME) depression presenting initially as tiredness be?
Its a clinical diagnosis
explore PMH further
invite them back to explain and discuss diagnosis and impact at a later date
What are the clues of environmental impacts for tiredness as a presenting complaint?
What are the investigations?
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
What are the key parts of information dealing with PUO?
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
