Haematology & Eyes Cases

Question 1

Your name is Tom and you are a 46 year old man. You have felt fatigued for the last 6 months. There is shortness of breath on exertion, but no chest pain/nausea/sweating. There is some dizziness upon standing up too quickly. This has never happened before. It seems to be getting worse.

Medical history

Nil

Family history

Sister is on thyroid tablets

Social history

Became a vegan 12 months ago

Provide information back to the doctor at the end of history taking if anything was not elicited

Questions

1) What systems review questions would you consider in this case?
2) How is the family history relevant?
3) How is the veganism relevant?
4) What investigations would be helpful?

Answer 1

1) What systems review questions would you consider in this case?

• Systems review
• Cardiac–cardiac symptoms, cardiovascular risk factors
• Thyroid
• Gastro
• Respiratory
• General red flags weight loss, night sweats, loss of appetite
• Psychological/social

2) How is the family history relevant?

• Thyroid conditions –most common are autoimmune diseases, which can run in families
• Thyroid conditions are an important common differential diagnosis for generalisedsymptoms such as fatigue as it affects multiple systems

3) How is the veganism relevant?

• Symptoms of anaemia
• One cause if B12 deficiency
• Vitamin B12 sourced from animal products
• Vegetarians also at risk

What investigations would be helpful?

Mainly blood tests

• Full blood count to diagnose anaemia
• B12 levels to diagnose deficiency
• Exclude common differentials
• Thyroid function tests
• Iron levels

Question 2

• You are Sandra, a 56 year old lady, divorcee. Over the weekend you had a girls’ getaway and had a great time. You went out Saturday night drinking, you had gotten dressed up and put your contacts in. You were a bit tipsy when you got home and slept with your contacts in even though you know you shouldn’t. The next morning your right eye became a bit sore and red and it has been getting worse. There’s not much discharge but your vision is a bit blurry. You see the doctor first thing Monday morning.

Background

Glaucoma Diabetes Hypertension Appendicectomy

Medications

Tablets for diabetes and hypertension Eye drops for glaucoma

No allergies
Social history
Medical receptionist, divorcee with two older teenage children.Provide information to the doctor that was missed on history taking Questions

1) What physical signs would you look for/test for?
2) What are the differential diagnoses based on history alone?
3) What are the broad management issues in this case?

Answer 2

1) What physical signs would you look for/test for?

• General inspection –redness, discharge
  
  • Look at different parts of the eye
  • Cornea clear?
  • Iris regular and reactive to light?
  • Any blood or pus in the anterior chamber (in front of the iris)?
  • Eyelid swelling, redness
• Flurosceinstaining for ulcers

2) What are the differential diagnoses based on history alone?

• Contact lens infection (of cornea or keratitis)
• Infections affecting other parts of eye
  
  • Iritis
  • Anterior uveitis
  • Endopthalmitis(whole eye infection)
• Acute glaucoma
• Retinal detachment (background risk factors hypertension and diabetes for retinopathy)

3) What are the broad management issues in this case?

Acute presentation

1. Find diagnosis
2. Serious red flag presentation
3. Urgent medical attention
4. Treat infection to prevent sight loss
5. Patient education about contact lens hygiene

Overall

1. Control cardiovascular risk factors
2. Control renal disease risk factors
3. Control diabetes to prevent complications
4. Ongoing care for glaucoma (chronic condition)