GP Flashcards
frailty
Frailty is a medical term regarding a state of physical or mental health of an individual.
It describes an individual’s ability to recover / respond to adverse health events.
features of frailty
slowness
exhaustion
wt loss
weakness
low PA
what is old age
Old age is the general slight slowing down physically and mentally of an individual.
This can be the accumulation of earlier life health decisions and overall wear and tear and general luck of genetics
An elderly individual is more likely to have comorbidities
generall >65/70
non medical mx non acute AF
address Risk Factors and Treat Underlying Cause
Reduce excessive alcohol and/or caffeine intake
Effective blood pressure management
Treat any underlying thyroid disease
Refer for echo and cardiology assessment if valvular heart disease and/or heart failure are suspected causes
mx paroxysmal AF
Infrequent or well tolerated paroxysmal AF or Known precipitants (e.g caffeine)
Consider no drug treatment or “pill in the pocket” strategy (B-blocker PRN)
Give patients information and reassurance
Frequent, symptomatic paroxysmal AF
Treat with regular B-blocker (e.g. atenolol) 50-100 mg OD
If not controlled refer for specialist management (e.g. amiodarone)
mx chronic AF
1st=rate control: Consider controlling ventricular rate with a B-blocker (e.g. Atenolol) or rate limiting calcium channel blockers (e.g. Diltiazem).
Aim for ventricular rate of 60-80 bpm at rest and 90-115 bpm for moderate exercise. If monotherapy does not control symptoms consider combination therapy with any 2 of: B-blocker, Diltiazem or Digoxin
2nd=rhythm control using cardioversion
when to refer for rhythm control in AF
Associated heart failure
Atrial flutter suitable for ablation
New onset AF
AF secondary to treated/corrected precipitant
If rate control unsuccessful/still symptomatic after rate is normalised
anticoagulation in AF
CHADVASC VS HASBLED
chadvasc
CHF
HTN
AGe >75
DM
stroke/TIA/VTE
vascular disease
age 65-74
female
1=condider antcoag
2=anticoag
HASBLED
HTN
abnormal renal or liver function
stroke
bleeding
labile INRs
>65
drugs or alcohol
score of 3+ = significnat risk bleed
RF falls
Increasing age
Multiple previous falls
Disorders of gait or balance
Visual impairment ->correct if possible, advise to get eyes tested
Cognitive impairment
Low morale/depression -> tx as necessary, support network
High level of dependence
Decreased mobility
Foot problems
Lower limb weakness or arthritis -> physio for strengthening
Hx stroke or PD
Use of psychotropic drugs, sedatives, diuretics, BB
Alcohol
Environment: loose rugs, poor lighting, ice, high winds ->OT visit
Infection e.g. pneumonia, UTI
medications increasing risk of falls
Digoxin toxicity – Blurry or yellow vision
Amitriptyline – Anticholinergic side-effects
Indapamide- Can precipitate gout
Medications causing postural hypotension: nitrates, diuretics, anticholinergic medications, AD, BB, L-dopa, ACEi ->alter medication, compression stockings
Medications associated with falls for other reasons: benzos, antipsychotics, opiates, anticonvulsants, codeine, digoxin, other sedative agents
falls assessment
identification of falls history
assessment of gait, balance and mobility, and muscle weakness
assessment of osteoporosis risk
assessment of the older person’s perceived functional ability and fear relating to falling
assessment of visual impairment
assessment of cognitive impairment and neurological examination
assessment of urinary incontinence
assessment of home hazards
cardiovascular examination (BP, HR and rhythm) and medication review.
mx falls
strength and balance training
home hazard assessment and intervention
vision assessment and referral
medication review with modification/withdrawal
Also need to tx conditions causing falls
EDUCATION COVERING:
what measures they can take to prevent further falls
how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components
the preventable nature of some falls
the physical and psychological benefits of modifying falls risk
where they can seek further advice and assistance
how to cope if they have a fall, including how to summon help and how to avoid a long lie.
benefits of patient centrered care
Improves satisfaction
Reduces perception of hierarchy
Improved resource allocation
Better outcomes for patients = prevention of future issues = reduced economic impact of illness
shared decision making
In essence – Involve family members and the patient in a discussion about how to proceed. Usually in complex cases when the safety of discharge/treatments are in question
problematic polyphamarcy
The prescribing of medicines that are no longer clinically indicated or appropriate or optimised for that person
Where the benefit of a medicine does not outweigh the harm
Where the combination of multiple medicines has the potential to, or is causing harm to the person
Where the practicalities of using the medicines prescribed to a person have become unmanageable or are causing harm or distress, for example where some medicines should be taken before food, others after food, some in the morning, some in the evening and others at multiple times during the day.
medication review
Seeking the person’s (and/or their carer’s) perspective of their medicines and how they will take them
Explaining what the medicine does
Assessment of whether the medicines are essential or not
Assessment of the person’s level of adherence to the medicines
Assessment of the effectiveness (both clinical and cost effectiveness) of the medicines
Assessment of the safety of the medicines, and consideration of whether a safer alternative may be available given the persons medicines record
Decision and actions regarding stopping or continuing the medicines
milia
Tiny pearly white papules
Nose, face and sometimes palate
Due to blocked sebaceous ducts
Up to 50% of babies
Reassure; they go away spontaneously
Erythema Toxicum Neonatorum
Red blotches with a central white vesicle
Each spot lasts around 24 hours
Unknown cause
Up to half of newborns in first week of life
The spots are sterile! This is a well baby - reassure again!
harlequin Colour Change
One side of the body flushes red; the other remains pale
Unknown mechanism, thought to be immature hypothalamic control of vasomotor system
10% of babies; between 2nd and 5th day of life
Generally considered harmless - reassure!
BUT: if persistent, consider AVM
single Palmar Crease
A common abnormality
Associated with various genetic disorders (not just Down’s!)
usually benign unless other features present
Thorough examination
Likely reassure
Heat Rash (Milaria)
Itchy red rash
More common when hot and humid
Keep baby cool
Maybe dress in fewer clothes
Keep fluids up
Ophthalmia Neonatorum (Neonatal Conjunctivitis)
Triad of purulent discharge, eyelid oedema and normothermia
Commonly caused by E. Coli exposure during delivery
Presents within the first month
Swab to confirm
Oral erythromycin
umbilical Granuloma
The umbilicus should dry, blacken and separate about 1 week after birth
Granuloma often described as a persistently wet umbilicus
check for infection (antibiotics needed)
Exclude patent urachus
Use silver nitrate cautery stick
colic
Very common
Usually ages up to 3 months
Repeated, unstoppable crying with rigid body and red face
Knees drawn up - no real association with abdo pain
More often in evening
No known cause, usually resolves spontaneously
Parents can try colic drops (break down excess GI gas)
Not evidence for Cow’s milk allergy or need to change feeds
neonatal sleeping
Issues around inconsistent sleep pattern, night feeding
Parental exhaustion
All babies have different sleep patterns
“Sleep when your baby sleeps”
Baby should sleep in the same room as parent for 6 months (night and day)
Newborn can be as high as 18 hours
By 4 months, twice as long asleep at night as during the day
From 6 months night feeds may not be necessary (12 hours sleep)
cows milk protein intolerance
ymptoms usually develop within a week of cow’s milk introduction, although they may be delayed for several weeks.
Reactions may be triggered by food ingestion, inhalation, or skin contact (rare).
The trigger is usually cow’s milk, however, it may be cow’s milk protein in maternal breast milk in infants who are exclusively breastfed (rare in IgE-mediated allergy).
IgE-mediated reactions usually occur following a small amount of milk, whereas non-IgE-mediated reactions usually occur after ingestion of larger volumes of milk.
Most affected children present by six months of age; onset is rare after 12 months of age.
Skin reactions - such as an itchy rash or swelling of the lips, face and around the eyes
digestive problems – such as stomach ache, vomiting, colic, diarrhoea or constipation
hay fever-like symptoms – such as a runny or blocked nose
eczema that does not improve with treatment
In severe cases can cause anaphylaxis
mx cows milk protein intolerance
Removing all cows’ milk from the child’s diet for a period of time.
If baby is formula-fed, can prescribe special infant formula.
If baby is exclusively breastfed, the mother will be advised to avoid all cows’ milk products.
Child should be assessed around every 6 to 18 months to see if they have grown out of their allergy.
failure to thrive
FAILURE TO GROW AT THE EXPECTED RATE
Mild?
fall across two centile lines
Severe?
fall across three centile lines.
indicators failure to thrive
Most sensitive indicator in infants and young children?
weight
In older children?
height
causes failure to thrive
most common=Not enough food (95%) This can be due to poverty, socioeconomic difficulties, emotional deprivation, unskilled feeding,
Organic causes
* Decreased appetite, e.g. psychological or secondary to chronic illness.
* Inability to ingest, e.g. GI structural or neurological problems.
* Excessive food loss, e.g. severe vomiting (gastro-oesophageal refl ux
disease (GORD), pyloric stenosis, dysmotility), diabetes mellitus
(urine).
* Malabsorption (see b p.334).
* Increased energy requirements, e.g. congenital heart disease, cystic
fi brosis, malignancy, sepsis.
* Impaired utilization, e.g. various syndromes, IEM, endocrinopathies.
ix failure to thrive
History
age of onset of FTT, and timing of weaning, food diary, meal times description, previous IUGR, other sx (D&V, fatigue), health of other children
dietary history from dietician
Examination:
Growth and systems
Signs of organic disease: distended abdo, chronic resp disease, heart failure,
If organic disease possible
FBC, ESR/CRP, U&E, creatinine, total protein and albumin, Ca2+,PO4 3 – , LFT, immunoglobulins, coeliac antibody screen
Urinalysis - ncluding M, C&S.
Further investigations: are indicated if there are suggestive symptoms or the faltering growth is severe,
IEM screen, karyotype, serum lead (pica), sweat test, upper endoscopy and small intestinal biopsy, CXR, bone age, skeletal survey (NAI), abdominal US, head CT/MRI, oesophageal pH monitoring, ECG, faecal occult blood.
mx non-organic failure to thrive
Provide dietetic input, whatever the cause, to support nutritional correction and education.
Identify and correct associated comorbidities, e.g. developmental delay
Input from a psychologist and social services may be useful
Important to manage effectively as severe FTT may be associated with developmental and behavioural impairment
when is hospital admission required in failure to thrive
<6m and severe FTT
normal infant crying
Increases in the early weeks of life and peaks around 6-8 weeks of age and usually improves by 3-4 months of age.
infant crying red flags
Truly excessive crying
Sudden onset
Parental post-natal depression may be a factor in presentation
Differentials for acute onset infant irritability
Raised intracranial pressure (ICP) (could be infection or injury)
Injury eg clavicle fracture, non-accidental injury
Incarcerated inguinal hernia
Infection e.g. urinary tract infection
Corneal foreign body/abrasion
Differentials for chronic onset infant irritability
Hunger – insufficient breastmilk? More likely if losing centiles
Excessiveness tiredness
Non-IgE cow milk / soy protein allergy
Lactose overload/malabsorption
Gastro-oesophageal reflux disease
management infant crying
Exclude medical cause
Parental education and reassurance. It is often helpful to explain to caregivers the potential causes of crying that have been excluded and the reasons for excluding each condition.
Assess parental emotional state and mother-baby relationship:
invite the parent/s to talk about how stressful it is to care for a baby who cries persistently.
ascertain whether the parent is worried that she/he is depressed
screen for postnatal depression using the Edinburgh Postnatal Depression Scale
RF GOR in infants
Transient/physiological in infants- ? Why
◦ Short, narrow oesophagus.
◦ Delayed gastric emptying.
◦ Shorter, lower oesophageal sphincter that is slightly above, rather than below, the diaphragm.
◦ Liquid diet and high caloric requirement, putting a strain on gastric capacity.
◦ Larger ratio of gastric volume to oesophageal volume.
* consumption of relatively large quantities of liquid feeds
and the fact that infants are frequently recumbent
Risk Factors
Pre-mature
Cerebral palsy
Repaired Diaphragmatic hernia
Repaired Oesophageal atresia
Obesity
Hiatus Hernia
complications GORD in infants
Pneumonia
- Dental erosions
- Otitis media
- Reflux oesophagition
when to suspect GORD in an infant
Suspect GORD in an infant (up to 1 year of age) or child if they present with regurgitation and one or
more of the following:
◦ Distressed behaviour shown, for example, by excessive crying, crying while feeding, and adopting
unusual neck postures.
◦ Hoarseness and/or chronic cough.
◦ A single episode of pneumonia.
◦ Unexplained feeding difficulties, for example, refusing to feed, gagging, or choking.
◦ Faltering growth.
* Note that:
◦ Children over 1 year of age may present with heartburn, retrosternal pain, and epigastric pain.
◦ Additional features such as episodic torticollis with neck extension and rotation may indicate the
presence of Sandifer’s syndrome.
red flags GORD in infants
Frequent, forceful (projectile) vomiting-Suggests hypertrophic pyloric stenosis in infants up to 2 months old.
Bile-stained (green or yellow-green) vomit
-Suggests intestinal obstruction.
Abdominal distension, tenderness, or palpable mass-Suggests intestinal obstruction or another acute surgical condition.
Blood in vomit (not caused by swallowed blood from a nosebleed or ingested from a cracked maternal nipple)- Suggests an important and potentially serious bleed from the oesophagus, stomach, or upper gut.
Bulging fontanelle or altered responsiveness (for example lethargy or irritability)-Suggests raised intracranial pressure (for example caused by meningitis).
Rapidly increasing head circumference (more than 1 cm each week); persistent morning headache and vomiting worse in the morning-Suggests raised intracranial pressure (for example caused by hydrocephalus or a brain tumour).
Blood in the stool-Suggest a variety of conditions, including bacterial gastroenteritis and infant cows’ milk protein allergy.
Chronic diarrhoea- Suggests cows’ milk protein allergy.
With, or at high risk of, atopy-Suggests cows’ milk protein allergy.
Dysuria-Suggests a urinary tract infection (UTI), especially when accompanied by featured such as fever irritability, lethargy, jaundice, haematuria,
and offensive urine.
Appearing unwell or fever-Suggests infection.
Onset of regurgitation and/or vomiting after 6 months of age or persisting after 1 year of age-Suggests a cause other than reflux, for example UTI.
mx GOR in infants
Reassurance and review
* For breastfed infants with frequent regurgitation and marked distress:
* If symptoms persist despite breastfeeding assessment and advice:
◦ Consider prescribing a 1–2 week trial of alginate therapy (for example Gaviscon® Infant).
* For formula-fed infants with frequent regurgitation and marked distress
* Reduce the volume of feeds only if this is excessive for the child’s weight (a total feed volume of 150 mL/kg body
weight over 24 hours [6–8 times a day] is usually recommended), then
* Offer a 1–2 week trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk)
unless the feeds are already small and frequent, then
* Offer a 1–2 week trial of feed thickeners, such as a pre-thickened formula (for example Enfamil AR® and SMA
Staydown®) or a thickener that can be added to the usual infant formula (for example Instant Carobel®).
- If this stepped care approach is not successful, stop the thickened formula and offer a 1–2 week trial of alginate therapy
(Gaviscon® Infant) added to formula. - If symptoms improve after a 1–2 week trial of alginate therapy:
◦ Continue with the treatment.
◦ Advise the parents or carers to stop treatment at regular intervals (for example every 2 weeks) in order to see if
symptoms have improved and if it is possible to stop treatment completely. - Trial of PPI/H2 receptor antagonist 4 weeks if still troublesome symptoms.
- Referral to paeds.
how to manage child abuse
Seek help from NSPCC helpline
All practices have a Local Safeguarding Children Board.
Document all concerns
FGM you must report to the police
If child is in immediate danger – consider the police
If only considering maltreatment, gather advice and have review appt
common causes tension headaches
stress
a lack of sleep
depression
anxiety
skipping meals
alcohol use
causes of migraines
Migraines may have a genetic cause, since the condition tends to run in families.
Other factors that could trigger it include:
stress
anxiety
hormone changes in females
bright or flashing lights
tobacco use
caffeine and alcohol consumption
sleeping too much or too little
strong smells
certain foods, such as:
chocolate
matured cheeses
processed meats
migraine features
Auras, emotional, stress, tiredness, food, bright lights, alcohol, chocolate
menstrual related migraine
- Headache symptoms coincide with menstrual period, few days before and after
medication overuse headache
Using medication for over 3 months, not helping
= triptans, opioids, paracetamol, aspirin, NSAIDs
>15 days a month
cluster headache
Severe unilateral pain, red eye, short to few hour duration
Repeated attacks then pain free period
red flag sx headaches
udden onset, thunderclap headache 🡪 SAH
Neck stiffness + Photophobia 🡪 Meningitis
New onset cognitive dysfunction/personality change 🡪 Lesion / haemorrhage
Decreased level of consciousness 🡪 raised intracranial pressure
Recent history of head trauma (<3months) 🡪 Subdural haemorrhage
Tender temporal region + jaw pain 🡪 Temporal artertitis
brain tumour sx
seizures, neausea, drowsiness, visual changes, speech problems, personality changes, progressive weakness/paralysis
psychosocial factors in headacches
education, stress, sleep, smoking
fitzpatrick skin types
A classification of skin based on how it reacts to sun exposure
A combination of constitutional colour (melanin) + UV sensitivity (tanning)
They are used mainly for classifying skin types for dermatological treatments or research studies
red flags in itch
Sudden onset itching
Rash covering entire body
Rash is non-blanching
Type of itching – burning = indicative of Hodgkin
Fevers / Night sweats / weight loss
local itch causes
Eczema – inflammation of dermis and epidermis usually by IgE hypersensitivity reactio
Dry skin – commonly seen in elderly patients due to trophic changes or venous changes on the legs and arms.
Psoriasis – Autoimmune condition causing abnormal keratinocyte growth
infections like scabies
hives/allergies - histamine release leads to fluid in dermis
eczema mx
Always emollient. Better ones are more paraphing based emollients and oat milk based. Zeroveen and Atroveen are good choices as little to no reactive compounds.
Topical steroid: 1%hydrocortisone cream to start
0.025% Betnovate
0.05% Betnovate
Dermovate
Beyond this – Specialist level care is required but Broad immunomodulators like Tacrolimus or Monoclonal antibody therapy
psoraisis mx
topical potent steroids + topical vit D
emollients
salicylic acid can reduce scaliness
light therapy
methotrexate and DMARDs
mx scabies
Wash all bedding and clothing and isolate contact with clothes and bedding to prevent spread
Permethrin 5% cream as an insecticide.
To treat the itch: Topical Tea tree oil and Calamine lotion can sooth the skin, Antihistamines orally can help calm the itch. Topical steroids can be used if this doesn’t work but needs prescription
mx hives/urticaria
Usually, Hives are best treated with OTC antihistamines like cetirizine
Sometimes, if hives persist, can trial local creams like Menthol creams.
Severe hives that aren’t going with usual treatments can need oral steroids like a short course of prednisolone
Chronic Urticaria can require Cyclosporins, Leukotriene receptor antagonists and Antibodies like Omaluzimab
systemic conditions rpesenting with itch
Renal failure
Liver disease
Iron deficiency anaemia
Polycythaemia
Hyper/hypothyroidism
Lymphoma
Diabetes mellitus
HIV infection
Drugs: opiates, statins, ACE-inhibitors, chloroquine
skin conditions presenting with itch
Lichen planus
Lichen simplex
Dermatitis herpetiformis
Atopic dermatitis (eczema)
Venous eczema
Asteatotic eczema
Scabies
Urticaria
Psoriasis
reasons patients make complainrs
Communications
Patient Care including Nutrition / Hydration
Values and Behaviour
mx medically unexplained sx
Relevant screening tests for organic disease based on body system (therapeutic investigations have very little effect on patients)
Clinicians worry about knowledge gaps but studies show they are more likely to make errors by discounting differentials too early
Good management is a compassionate explanation of the situation
Some patients welcome syndrome based descriptors because they validate their experience
Some will also desire a detailed explanation of how their body may be dysfunctional
Management techniques: self-management support, CBT and pharmacotherapy
ix for sensory disturbance
bloods: DM, thyroid, alchoho, B12/folate
neuro imaging
may need same day neuro referral
mental state examination
Appearance
Behaviour – Speech, Affect, Movement
Thought – Content, Form
Cognition – Orientation and perception
Inisght – Awareness of illness
mononeuropathy
Mononeuropathies result in a localised sensory disturbance in the area supplied by the damaged nerve
radiculopathy
Radiculopathy occurs due to nerve root damage and results in sensory disturbances in the affect dermatomes
peripheral neuropathy
Peripheral neuropathy typically causes symmetrical sensory deficits in a “glove and stocking”
causes peripheral neuropathy
DM
shingles-post herpatic neuralgia
B12 deficiwncy
alchol
AI-RA, SLE
lyme disease
syohilis
HIV
toxins
heriditary - charcot-marie tooth
thalamic lesions
Thalamic lesions result in contralateral sensory loss. The most common cause of a thalamic lesion is a stroke.
spincal cord damage
Spinal cord damage results in sensory loss both at and below the level of involvement, in a dermatomal pattern, due to the impact of injury on the sensory tracts running through the cord.
descending tracts
motor
lateral corticospinal
veritcal corticospinal tract
ascending tracts
sensory
dorsal columns - deep touch, vibration, proprioception
lateral spinothalamic - pain, temp
ventral spinothalamic - light touch
life ending measures
Removal of equipment otherwise keeping the patient alive
Stopping of medications
Expediting their passing with medication
Withholding further treatment
Refusing to eat or drink
Refusing to take medications
advanced statement
Written statement that sets down the preferences, wishes, beliefs and values regarding the future care of the patient.
Aims to provide a guide to anyone who might have to make decisions in their best interest if they have lost the ability to make or communicate decisions.
Can cover any aspect of their future health or social care:
how they want any religious or spiritual beliefs to be reflected in their care
where they would like to be cared for, for example at home or in a hospital, a nursing home, or a hospice
how they like to do things, for example if they prefer a shower instead of a bath, or like to sleep with the light on
practical issues, for example who will look after their dog if they become ill
An advance statement is not legally binding, but anyone making decisions about their care must take it into account.
Advance Decision or Living Will
A decision a patient can make now to refuse a specific type of treatment at some time in the future.
It lets the family, carers and health professionals know their wishes about refusing treatment if they’re unable to make or communicate those decisions themselves.
Treatments they’re deciding to refuse must all be named in the advance decision. It need to be clear about all the circumstances in which they want or don’t want to refuse this treatment.
Advice Decisions and Life-Sustaining Treatments
With an advance decision the patient can refuse a treatment that could potentially keep them alive.
In order to refuse life-sustaining treatment advance decisions need to be:
written down
signed by the patient
signed by a witness
Advance Decision
An advance decision is legally binding as long as it:
complies with the Mental Capacity Act
is valid
applies to the situation
An advance decision may only be considered valid if:
they’re aged 18 or over and had the capacity to make, understand and communicate their decision when they made it
they specify clearly which treatments they wish to refuse
they explain the circumstances in which they wish to refuse them
it’s signed by them (and by a witness if they want to refuse life-sustaining treatment)
they have made the advance decision of their own accord, without any harassment by anyone else
they have not said or done anything that would contradict the advance decision since they made it (for example, saying that they’ve changed their mind)
If it’s valid and applies to the situation, an advance decision gives their health and social care team clinical and legal instructions about their treatment choices.
An advance decision will only be used if, at some time in the future, they’re not able to make their own decisions about their treatment.
Lasting Power of Attorney
Gives another person the right to make decisions about the patients care and welfare
They can appoint just 1 attorney, or more than 1 attorney, to act.
A health and welfare LPA gives their attorney the power to make decisions about their daily routine (washing, dressing, eating), medical care, moving into a care home and life-sustaining medical treatment. It can only be used if they’re unable to make their own decisions.
If the patient made a decision to refuse future medical treatment (advance decision) in advance of losing their mental capacity, the attorney cannot override their decision unless the LPA was made later and specifies that they have the power to do so.
stopp
STOPP-this is a tool used too reduce the prescription of unnecessary drugs in the
palliative patient
redmap framework
ready - can we talk about health and care
expect - what do you know
diagnosis
matters - what is important
actions - what we can do
plan
advance care planning
think about future
talk with family and friends
record thoughts
discuss planw with dr
share this info
ALT + AST
liver enzymes found in hepatocytes -> leak into blood stream when the liver is damaged / inflamed
ALT + AST can be raised in conditions involving liver scarring (NAFLD and ARLD)
ALP + GGT
can be indicative of obstruction / cholestatic liver disease
Alkaline Phosphatase is also involved in the bile duct and bones meaning its not just liver specific.
GGT
can indicate alcohol usage and NAFLD
tiredness causes
endo: DM, diabetes insipidus, testosterone deficiency, menopause, thyroif, obesity
cardiac: HF
renal failure
rheum: OA, SLE, PMR, IA
infection: HIV, hep, EBV
gastro: coeliac, IBD
neuro: migraine, MS, narcoplepsy, insomnia
psychogenic: fibromyalgia, stress, depression, anxiety, ME CFS
haem: anaemia, polycythaemia
malignancy
