Tiredness Flashcards
Why does Mina come in to see the GP?
feels tired all the time
cannot understand why
feels like being surrounded by fog
How has the tiredness been impacting Mina’s life?
has to change her working patterns because the later it gets the less productive she is
takes afternoon naps on the weekend
What does her lifestyle look like?
vegetarian
but quality of diet depends
works hard at staying fit - put on weight over the summer
Any other symptoms?
skin is dry
Family history?
sister went to the doctor for tiredness but was diagnosed with vitamin D deficiency
What does the GP suggest?
MOT
simple blood tests
look at lifestyle to see if there are any contribution factors
What is the difference between tiredness and fatigue?
Fatigue is when the tiredness is often overwhelming and isn’t relieved by sleep and rest.
What are the 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 the most common medical reasons for feeling run down?
Iron deficiency anaemia
Who is prone to anaemia?
Women with heavy periods
Pregnant women
What are less common causes of anaemia?
Ulvers
NSAIDS
What is sleep apnoea?
condition where your throat narrows or closes during sleep and repeatedly interrupts your breathing
What does sleep apnoea result in
loud snoring and a drop in your blood’s oxygen levels
The difficulty in breathing means you wake up often in the night and feel exhausted the next day
Who is sleep apnoea most common in?
overweight middle-aged men
Drinking alcohol and smoking makes it worse
What is an under-active thyroid?
Too little thyroid hormone (thyroxine) in your body
This makes you feel tired
What are other symptoms of having an under-active thyroid?
Weight gain
Aching muscles
Dry skin
What is coeliac disease?
lifelong disease caused by the immune system reacting to gluten
What are the symptoms of coeliac disease?
tiredness, diarrhoea, bloating, anaemia and weight loss
What is chronic fatigue syndrome also known as?
myalgic encephalomyelitis, or ME
What is chronic fatigue syndrome?
severe and disabling fatigue that goes on for at least 4 months.
There may be other symptoms, such as muscle or joint pain.
What is glandular fever?
common viral infection that causes fatigue, along with fever, sore throat and swollen glands
What is restless legs?
overwhelming urge to move your legs, which can keep you awake at night
What is GAD?
Generalised anxiety disorder
What percentage of GP consultations are for fatigue?
7%
To the nearest 10%, what percentage of patients who present to a GP with fatigue have a diagnosis made?
66%
To the nearest 10%, what percentage of patients who present to a GP with fatigue have a condition that is detected on blood tests?
<10%
Give other possible causes of fatigue?
Cancer Autoimmune disease Side effects of medication Diabetes Vitamin D deficiency Eating Disorder Fibromyalgia Pregnancy
What to BMJ Best Practice say are causes of fatigue?
Chronic heart failure
TB
Stroke
Addison’s
LOTS
Suggest 4 differentials for Mina?
Hypothyroidism
Vitamin D deficiency
Anaemia
Diabetes
What suggests that Mina has hypothyroidism?
Low metabolic rate Cold intolerance Weight gain Constipation Dry skin Slow heartbeat
What tests would we conduct in Mina?
FBC U&E Vitamin D Thyroid function tests HbA1c
What were the results of Mina’s TFTs?
TSH high
T3/T4 low
Primary hypothyroidism
What does Mina have?
Hashimoto’s
Describe what happens in Hashimoto’s
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)
What are the strategies to sift out the physical causes of tiredness?
Define the type of tiredness
Why did the patient present with this?
Screen for red flags
Explore and psychosocial triggers
Examine the patient (pulse, BP and BMI)
The plan
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?
chronic immune thyroiditis
How can hashimotos be detected clinically?
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
