Mina Flashcards
What does Mina’s patient profile tell us?
Worried about what is causing her tiredness, researched online
Mina flies frquently to scout out the latest trends in fashion
Flying is making her skin dry
Enjoys yoga several times a week, finds this more difficult with her fatigue
Drinks multiple cups of coffee a day to stay alert and focussed at work
Feels cold, always wears a scarf
Received indoor plant as a gift
What does Mina talk about in her Case video?
25/08/1988
Feels tired all the time
Feels like she’s surrounded by fog
The later the day gets, the more her tiredness increases and affects her work
Normally gets 6-7 hours of sleep, now struggling to get up in the mornings and taking afternoon naps on weekends
Buyer for Harrods - involves a lot of travelling (quite sure work is not her reason for tiredness)
Not stressed - sees girlfriend on weekends
Lives alone in Sloane Square
Vegetarian - diet fluctuates depending on workload
No alcohol, no smoking, no recreational drug use
Airplane skin - dry skin from flying
Sister = tiredness = Vit D deficiency
Mother = tiredness = diabetic
Working out extra hard recently to shed extra weight she gained over summer
What examinations does the doctor carry out on Mina over video?
Fit bit - HR = 55 (she says that’s good for her)
Eyes / pupils normal
No gland swelling
What does the doctor tell Mina in the case video?
Many reasons for tiredness
Wants to do a blood test to look for common causes
Wants to look at her lifestyle to see contributing factors and implement changes
Another consultation after the blood test
What’s the difference between tiredness and fatigue?
Tiredness = relieved by rest and sleep Fatigue = overwhelming tiredness that isn't relieved by rest and sleep
What are 10 medical reasons for feeling tired?
Anaemia Sleep apnoea Underactive thyroid Coeliac disease Chronic fatigue syndrome Diabetes Glandular fever Depression Restless legs Anxiety
What is anaemia and how can it cause tiredness?
Most likely iron-deficiency anaemia
Low RBC count
Mainly affects women with heavy periods or during pregnancy
In others, may be due to ulcers or NSAIDs
Or haemochromatosis = iron overload
Can lead to tiredness
What is sleep apnoea and how can it cause tiredness?
Throat narrows or closes during sleep and repeatedly interrupts breathing
Results in loud snoring and a drop in blood’s oxygen levels
Constant waking up at night and lack of O2 = exhaustion during the day
Most common in overweight, middle aged men (drinking and alcohol makes it worse)
What is an underactive thyroid and how can it cause tiredness?
Too little thyroid hormone (thyroxine)
Likely to put on weight and have aching muscles and dry skin
Most common in women
What is coeliac disease and how can it cause tiredness?
Immune system reacting to gluten
What is chronic fatigue syndrome and how can it cause tiredness?
AKA myalgic encephalomyelitis, or ME
Severe and disabling fatigue that goes on for at least 4 months
What is diabetes and how can it cause tiredness?
Body’s inability to control BGL using insulin
What is glandular fever and how can it cause tiredness?
Common viral infection that causes fatigue
Usually in teenagers and young adults
What is depression and how can it cause tiredness?
Constant low mood / anhedonia
Can stop you falling asleep or cause you to wake up early
What are restless legs and how can it cause tiredness?
Overwhelming urge to move your legs, which can keep you awake at night
May have unpleasant crawling sensation or deep ache in legs
Legs may jerk spontaneously
Disrupted sleep quality
What is anxiety and how can it cause tiredness?
Constant uncontrollable feelings of anxiety that affect their daily life
Affects women slightly more than men, feeling worried and irritable can lead to tiredness
What percentage of people present to the GP with fatigue?
What percentage of patients who present to a GP with fatigue have a diagnosis made?
What percentage of patients who present to a GP with fatigue have a condition that is detected on blood tests?
7%
2/3
<10%
What are some possible causes of fatigue?
Sleep apnoea Hypothyroidism Anaemia Coeliac disease Chronic fatigue syndrome Diabetes Glandular fever Depression Restless legs Anxiety Cancer Medications Diabetes Vit D deficiency Chronic pain - fibromyalgia Autoimmune - cushing's Malnutrition - eating disorders Pregnancy Arthritis / Rheumatoid Lupus Heart failure Infection Restless legs CKD
What is the differential diagnosis for Mina’s fatigue?
Hypothyroidism - dry skin, fatigue
Anaemia - fatigue, vegetarian
Vitamin D deficiency - fatigue, vegetarian, family history
Diabetes - family history
More history about Mina: Put on a stone since summer She rarely gets ill, last time she had a virus was years ago Good mood No stiffness or aches No periods - coil BC No much change in bowel habits, maybe constipated lately Feels cold - has to put on more layers
Using this, what are the top 2 differentials?
1. Hypothyroidism: Fatigue Dry skin Feels cold - has to put on more layers Constipation
- Anaemia
Fatigue
Vegetarian
Feels cold - has to put on more layers
What would be less likely for Mina?
Sleep apnoea - no snoring / waking up at night
Glandular fever - no high temperature
Lupus - no rash
Pregnancy - not pregnant
Pick 4 relevant blood tests to order for Mina and why:
FBC (Full blood count) U&E (Urea and electrolytes) Vitamin D TFT (thyroid function tests) CRP (C-reactive protein) Coeliac screen Autoimmune screen EBV serology HbA1C
TFT - check for hypothyroidism
FBC - check for anaemia, infection
Vit D - check for Vit D deficiency due to family history
U&E
[Autoimmune screen - specific panel of tests = although these tests are v. specific and can have you going down the wrong path]
CRP is raised in infections and malignancies
Mina is found to have a goitre - swollen smooth thyroid gland
Her blood tests show:
TSH 18 mU/L
Free T4 1.2 pmol/L
Free T3
What is the diagnosis for Mina?
Hypothyroidism Dry skin Weight gain Feeling cold Fatigue
Blood tests show high TSH levels but low T3 and T4 levels = primary hypothyroidism
“An under-active thyroid often occurs when the immune system, which usually fights infection, attacks the thyroid gland. This damages the thyroid, which means it’s not able to make enough of the hormone thyroxine, leading to the symptoms of an under-active thyroid. A condition called Hashimoto’s disease is the most common type of autoimmune reaction that causes an under-active thyroid.” - NHS
What is the mechanism that causes immune cells to attack thyroid cells in Hashimoto’s disease?
APC uses MHC-II molecule to present thyroid antigens to T cells
Cytotoxic T cells and B cells go damage the thyroid cells
APCs process antigens presenting them to T-cells
In hashimoto’s self-antigen is presented on MHC II to TCR
Look at POM notes (Immune tolerance)
Why don’t immune cells attack host cells?
Adaptive cells:
T cells and B cells during development in bone marrow and thymus are exposed to all types of proteins, then taught not to recognise the ones from the body
Innate cells:
Recognise pathogen associated molecular patterns (PAMPs) - peptidoglycan, lipipolysaccharide, lipoteichoic acid, mannan, flagella proteins etc.
Trained to act on only these
How can you explain Hashimoto’s and autoimmune disease to Mina?
The body’s immune system fails to recognise your own body tissues i.e. the thyroid gland as itself, and starts attacking it
Video on how to Approach a Patient with Tiredness:
What are the 7 steps to sift out physical causes for tiredness?
2/3 of ‘tiredness’ episodes are triggered by life stresses
Strategy to sift out physical causes:
- Define the type of tiredness:
Drowsiness, short of breath or weakness? Exertional tiredness = physical
OK when they wake up but more tired as they do things = worrying
Rubbish when they wake up but ok when they do things = not worrying - Why did this patient present?
Look for functional impairment - Screen for red flags:
lymphadenopathy, weight loss, psecific malignancy deatures, joint pains, focal neurology, infective symptoms - Explore psychosocial triggers - work, money, family, mood, drugs and alcohol
- Examine the patients - history + pulse, BP, BMI
- Plan blood tests for: FBC (anaemia, haemotological malignancy, iron deficiency), thyroid function, ESR, glucose
- Management of persisting unexplained tiredness with normal initial bloods
What are red flags when it comes to tiredness?
Lymphadenopathy
Weight Loss
Specific malignancy features focus on: lung, breast, colon, upper GI and Gynae
Join pains
Focal neurology
Infective symptoms e.g. glandular fever and lyme
What could be psychosocial triggers?
Mood Drugs and Alchohol Family Work Money
What questions with someone with hypothyroidism ask their doctor?
Why did I get an underactive thyroid?
• Will I get better?
• Do I need treatment?
• What’s the best treatment for me?
• Will I need to have treatment for the rest of my life?
• What are the side effects of treatment? How can I cope with them?
• Should I change what I eat?
• What are the chances that someone else in my family will get an underactive thyroid?
Does it run in families?
• How will my treatment be managed if I wish to get pregnant (women)?
How would you explain to a patient the action of thyroxine?
Helps to control how fast your body makes and uses energy from food
What are the symptoms of hypothyroidism?
Feeling tires or depressed Thinking more slowly or less clearly than usual Having dry skin Putting on weight Feeling the cold more than usual Having constipation Irregular periods
What might someone with hypothyroidism notice over many years?
Dry, flaky skin Coarse hair or hair loss Put on weight even though caloric intake is the same Feel depressed Feel sluggish Have a hoarse voice
How is hypothyroidism treated?
Levothyroxine replacement for life
One a day on an empty stomach (100-150mg)
Start on low dose then increase
What might happen if you take too much thyroxine?
Atrial fibrilaton
Bone thinning
What can cause hypothyroidism?
Autoimmune 'Hashimoto's' Radioactive iodine treatment Thyroid surgery Antithyroid drugs Lithium drugs Cough medicines Health foods in excess Malfunction of the pituitary gland Radiation for head and neck cancers
What is mild thyroid failure or subclinical hypothyroidism?
Very slight hypothyroidism
No obvious symptoms
Raised TSH and normal FT4
What should happen if you get pregnant?
Increase dose by 25-50mcg
TFTs asap
What can trigger graves and hashimotos?
Stress
Pregnancy
Genetics
What is the more appropriate name for hashimotos?
How can hashimotos be detected clinically?
Chronic immune thyroiditis
Presence of antibodies
Rise in TSH
Low blood thyroxine
Give two ways that hypothyroidism can present?
Goitrous autoimmune thyroiditis
Atrophic autominnue thyroiditis
What are the main features of goitrous autoimmune thyroiditis?
Progressive infiltration of white cells enlarges the thyroid
Goitre formation
Worsened by increase in dietary iodine
What are the main features of atrophic autoimmune thyroiditis?
Most common form
Thyroid gland shrinks with progressive loss of tissue
Antibodies block the TSH receptors
