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ILAs > Tired all the time > Flashcards

Tired all the time Flashcards

1
Q

What are medically unexplained symptoms?

A

Medically Unexplained Symptoms are persistent bodily complaints for which adequate examination (including investigation) does not reveal sufficiently explanatory, structural or other specified pathology.

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2
Q

How common is MUS?

A

MUS are very common.
Estimated that MUS accounts for 45% of general practice consultations.
50% of patients with MUS have no diagnosis after 3 months.

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3
Q

Which symptoms are commonly MUS?

A 
Muscle or joint pain
Back pain
Headaches
Tiredness
Feeling faint
Chest pain
Heart palpitations
Stomach pain
Bloating
Diarrhoea
Constipation
Collapsing
Fits
Breathlessness
Paralysis
Numbness
Tingling
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4
Q

What causes MUS?

A 
Unknown
Theories:
Psychological distress or disturbance
Reaction to childhood trauma
An individual’s personality and psychological characteristics and predispositions
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5
Q

What are the risk factors for MUS?

A

Female
Childhood abuse/trauma
Serious illness/death of a close family member

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6
Q

What is the impact of MUS?

A

Patients experience stress, distress and anxiety because they do not have a diagnosis and investigations come back as normal
Many patients report that they don’t feel like they are taken seriously by healthcare professionals
Can lead to a breakdown in the patient-clinician relationship

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7
Q

What is the treatment for MUS?

A

Combination of the following tailored to the patient:
Physical exercise
Stress management
CBT
Mindfulness-based cognitive therapy
Antidepressants - particularly for those with comorbid depression

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8
Q

What is the purpose of doing investigations?

A

Screening - identifying people who do not yet show symptoms, to analyse a patient’s predisposition for developing a disease
Make a specific diagnosis of a particular illness (or to exclude one or more differential diagnoses)
To assess the degree of development of a disease and estimate prognosis
To assess whether the chosen treatments are effective

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9
Q

What is FBC used for?

A

Used to diagnose infection, anaemia, leukaemia, blood disorders and a patient’s general health.

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10
Q

What is ESR?

A

Increased when there is inflammation present due to more fibrinogens and immunoglobulins.

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11
Q

What are TFT?

A

Thyroid function tests

Measures levels of T3, T4 and TSH.

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12
Q

What do U&Es do?

A

Assesses renal function and electrolyte balance, creatinine also included in this test.

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13
Q

Why would you measure calcium?

A

Used to diagnose a range of conditions related to the bones, heart, nerves, kidneys and teeth.

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14
Q

Why might you have raised CK?

A

Raised levels may be due to a heart attack, skeletal muscle injury, or strenuous exercise.

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15
Q

Why measure phosphate levels?

A

Aids diagnosis of hormonal problems associated with parathyroid hormone and Vitamin D.

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16
Q

Why measure ANAs?

A

Used to diagnose SLE, Sjogren’s, Scleroderma and certain other autoimmune disorders.

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17
Q

Why measure immunoglobulins?

A

Used to diagnose bacterial/viral infection, immunodeficiency or autoimmune disorders.

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18
Q

Why are we at risk of over-investigation?

A

Societal culture of risk aversion
Increased medical litigation
Increase in technological advances and more tests than ever before

These tests need to be used wisely otherwise we are at risk of inducing more harm to patients who are already unwell

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19
Q

What are the harms associated with over-investigation?

A

Harms of the test itself - patient’s time off work, needle phobia, bruising, vasovagal syncope
Workload and financial costs - costs of the test itself as well as the analysis of it
Medicalisation of the patient’s problem - patients or clinicians focusing only on biomedical aspects of complex illness
Patient anxiety
Harms of overdiagnosis

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20
Q

Why might the patient’s expectation be different to that of the healthcare professional?

A

A clinician will tend to view successful care in terms of clinical outcomes.
Patients are much more likely to place importance on other factors.
These can include the emotional impact of the experience, or whether or not they feel cared about and cared for by the clinician.

21
Q

What factors impact a patient’s expectations?

A

Too much information: patients may come with preconceptions about how they will be treated, websites with inaccurate information, based on their past expectations of the experiences of friends or relatives.
Lack of information: patients may not have been appropriately informed about what to expect of treatment.
Contradictory advice: they may view uncertainty about diagnosis or treatment, or inconsistent advice, as indicating that one or more of their doctors is wrong.
Anxiety: makes misunderstandings more likely.
Time pressures: Short appointment times can mean it’s difficult to spend enough time talking to a patient to check they fully understand the issues involved in their care, whether diagnostic uncertainty, complications of treatment, or different treatment options.

22
Q

How, as PAs, can we avoid a mismatch in expectations?

A

Communicate in a way the patient can understand, different needs and levels of understanding. Try to avoid medical terminology, abbreviations and jargon and involve close family/friends if appropriate.
Check understanding and let the patient ask questions: asking them to repeat what you’ve said, and you may wish to offer a further appointment to go through things again.
Show empathy and understanding: good supportive and professional relationship with your patient goes a long way to gaining their trust, this will improve their experience..
Be open to feedback: Develop an informal, non-confrontational way for patients to discuss concerns or leave feedback.

23
Q

What is Fibromyalgia?

A

A chronic pain syndrome diagnosed by the presence of widespread body pain (front and back, right and left, on both sides of the diaphragm) for at least 3 months with tenderness.

24
Q

What causes Fibromyalgia?

A

Abnormal pain messages - changes to chemicals in the CNS result in constant feelings of and extreme sensitivity to pain
Chemical imbalances e.g. low levels of serotonin, noradrenaline and dopamine
Sleep problems
Genetics
Triggers e.g. injury, viral infection, giving birth, having operation
Assoc conditions e.g. osteoarthritis, lupus, rheumatoid arthritis, ankylosing spondylitis

25
Q

What is the pathology behind Fibromyalgia?

A

Primary pathology in CNS (brain and spinal cord) and involves pain and/or sensory amplification
Hallmark = hyperalgesia (increased pain in response to normally painful stimuli) and/or allodynia (pain in response to normally non-painful stimuli)
These individuals may have problem with augmented pain or sensory processing i.e. increase gain setting in CNS rather than pathological abnormality confined to area of body where person is experiencing pain
Appears to be in part due to imbalances in levels of NTs affecting pain and sensory transmission
CNS mediated symptoms other than pain (fatigue, memory difficulties, sleep and mood disorders) are frequent co-morbidities

26
Q

What are the risk factors for Fibromyalgia?

A

Family history
Rheumatological conditions
20-60 years of age
Female gender

27
Q

What are the differentials for Fibromyalgia?

A

Myofascial pain syndrome - pts with this do not have widespread central sensitisation
Vitamin D deficiency - serum 25-hydroxyvitamin D level is low

28
Q

What are the clinical features of Fibromyalgia?

A 
Chronic pain
Diffuse tenderness on examination
Fatigue unrelieved by rest
Sleep and mood disturbance 
Cognitive dysfunction
Headaches
Numbness/tingling sensations 
Stiffness
Fluid retention
Sensitivity to sensory stimuli e.g. bright lights, odours
29
Q

What investigations would you do for potential Fibromyalgia?

A

Presence of chronic >3 months widespread body pain in muscles and joints, plus at least 11 of 18 tender points

30
Q

What are the pharmacological treatments for Fibromyalgia?

A

1st line: amitriptyline - antidepressant to boost levels of NT
OTC medication e.g. paracetamol
Medication for sleep
Muscle relaxants for stiffness or spasms e.g. diazepam
Anticonvulsants usually used for epilepsy but can improve pain e.g. pregabalin
Antipsychotics sometimes used to relieve long term pain
Alternative therapies e.g. acupuncture, massage, aromatherapy

31
Q

What are the non-pharmacogical treatments for Fibromyalgia?

A

Non-pharmacological therapies e.g. exercise – aerobic exercise improves peak oxygen uptake and decreases pain intensity and fatigue; strength training reduces severity of fibromyalgia symptoms; aquatic exercise assoc with improvements in pain, higher QOL, physical function, muscle strength, emotional and mental health and vitality; multidisciplinary programmes improve tenderness severity. Too much could mean an increase in symptoms e.g. stiffness, pain and fatigue and musculoskeletal problems e.g. plantar fasciitis (inflammation of foot)

32
Q

Who should be treating a patient with Fibromyalgia?

A

GP - helps decide what is best for patient
Rheumatologist
Neurologist
Psychologist
Support groups e.g. Fibromyalgia Action UK

33
Q

What is chronic fatigue syndrome?

A

Defined as persistent disabling fatigue lasting >6 months, affecting mental and physical function
Considered to be a ‘functional somatic syndrome’ 🡪 illnesses in which no obvious pathology is found and there is assumed dysfunction of an organ or system.

34
Q

Give some examples of some functional somatic syndromes?

A

Chronic fatigue syndrome, tension headaches, fibromyalgia, multiple chemical sensitivity, irritable bladder.

35
Q

What are the predisposing factors for functional somatic syndromes?

A

Predisposing factors such as perfectionist and introspective personality traits, childhood trauma and similar illnesses in first degree relatives. Triggering factors such as infections, traumatic events, life events that caused a change in behaviours e.g taking time off work.

36
Q

What are the symptoms of chronic fatigue syndrome?

A

Fatigue, headaches, loss of memory/concentration, sleeping problems, muscle pain, sore throat

37
Q

What is the diagnostic criteria for chronic fatigue syndrome?

A

PLUS ≥4 of: myalgia (~80%), polyarthralgia, memory, unrefreshing sleep, fatigue after exertion >24h, persistent sore throat, tender cervical/axillary lymph nodes.

38
Q

Who normally gets chronic fatigue syndrome?

A

Prevalence 🡪 0.5-2.5% worldwide

Occurs most commonly in women age 20-50

39
Q

What causes chronic fatigue syndrome?

A

Not known what causes CFS, several theories. Potential causes:

  • CFS can be triggered by certain infections, such as infectious mononucleosis and viral hepatitis. About 12% patients who have infectious mononucleosis have CFS 6 months after onset of infection but there is no evidence of persistent infection.
  • Problems with immune system
  • Hormone imbalance
  • Mental health problems such as stress and emotional trauma
  • Genes, seems to be more common in some families. Genetic predisposition where stress related events at as triggers.
40
Q

How does chronic fatigue syndrome present?

A

Cardinal symptom 🡪 chronic fatigue made worse by minimal exertion.
Fatigue is both mental and physical
Poor concentration, impaired registration of memory, alteration in sleep pattern, muscular pain, myalgia (~80%), polyarthralgia, fatigue after exertion >24h, persistent sore throat, tender cervical/axillary lymph nodes.

41
Q

What are the different levels of severity in chronic fatigue syndrome?

A

Mild 🡪 individual generally able to carry on everyday activities, such as their work or education, or housework, but with difficulty.
Moderate 🡪 individual can’t move around easily and have problems continuing normal levels of daily activities. May have to give up their work or education, may need to sleep in the afternoon, rest frequently between activities, and have problems sleeping at night.
Severe🡪 individual only able to do very basic daily tasks such as cleaning teeth, or may need help even with these. May be housebound or even bedbound most or all of the time and need a wheelchair to get around. They have problems with learning, memory and concentrating, and are usually very sensitive to noise and light.

42
Q

How would you investigate chronic fatigue syndrome?

A

No specific test for CFS/ME, so is diagnosed based on symptoms and by ruling out other conditions that could be causing these symptoms.
Take medical history and perform physical examination 🡪 Establish prolonged and severe fatigue. Any possible medications causing symptoms.
Blood tests and urine tests to rule out other conditions, such as anaemia (lack of red blood cells), an underactive thyroid gland (TFT’s), or liver and kidney problems.
Often delayed diagnosis of CFS/ME as other conditions with similar symptoms need to be ruled out first.

43
Q

What’s the differentials for chronic fatigue syndrome?

A

Very common

  • Anaemia
  • Thyroid disorders
  • Sleep apnoea

Common

  • Chronic infection 🡪 HIV, hepatitis C, lyme disease.
  • Cancer
  • Pulmonary 🡪 asthma, COPD

Uncommon

  • Polymyositis
  • Dermatomyositis
  • Myasthenia gravis
  • Multiple sclerosis
44
Q

What are the management strategies for chronic fatigue syndrome?

A

Stop drugs
Sleep management advice
Rest period introduced to daily routine
Diet - increase slow release starchy foods and snacks
Recommend flexible adjustments or adaptations to work or studies to help people with CFS

45
Q

What are the rehabilitative therapies for chronic fatigue syndrome?

A

CBT - Recording and analysing patterns of activity and rest, and thoughts, feelings and behaviours, Establishing a stable and maintainable activity level (baseline) followed by a gradual and mutually agreed increase in activity, Identify triggers
Graded exercise therapy - With regular exposure to a low level activity, the body begins to adapt and gradually increase an individuals tolerance to carrying out that activity, for around three months to reduce inactivity and improve fitness.

46
Q

What is the aim of the rehabilitative therapies for chronic fatigue syndrome?

A

Individualised, person-centred programme The objectives of the programme should be to, sustain or gradually extend, if possible, the person’s physical, emotional and cognitive capacity. Manage the physical and emotional impact of their symptoms.

47
Q

What is the pharmacological treatment for chronic fatigue syndrome?

A

Specific antidepressants for mood disorders, analgesia and sleep disturbance e.g 10-50mg amitriptyline at night for sleep and pain
Symptomatic medicines e.g appropriate analgesia, taken when necessary.

48
Q

What are the alternative treatments for chronic fatigue syndrome?

A

Acupuncture 🡪 positive results from observational studies but not sufficient evidence from randomised controlled trials. Causing release of NTs, reduce sensitivity to stress and pain, increasing relaxation.
L cartinine 🡪 cartinine found in nearly all body cells, responsible for transporting long-chain fatty acids into mitochondria. It allows these fatty acids to be converted into energy. Some studies have found that carnitine levels are decreased in people with CFS.
Ginseng a herb in Asia used to treat fatigue.
Nicotinamide adenine dinucleotide (NADH) is a naturally occurring molecule formed from vitamin B3 (niacin), plays role in cellular energy production.
Coenzyme Q10 (CoQ10) is a compound found naturally in the mitochondria.

49
Q

What is the prognosis for chronic fatigue syndrome?

A

Poor without treatment, less than 10% hospital attenders recovered after one year.
Outcomes worse with greater severity, increasing age, comorbid mood disorders and conviction illness is entered physical.
Thought that 60% improve with active rehabilitative treatments such as graded exercise therapy and cognitive behaviour therapy when added to specialist medical care.

ILAs (14 decks)

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