Week 3 - Infertility and tiredness Flashcards
Mr. TD is a 42-year-old man who has been recalled to discuss his blood test results. He came in initially for investigation of infertility and tiredness which had been present ‘on and off’ for a few years.
Take a history of this patient.
HPC:
• Fatigue: 2 years, tired. Otherwise healthy, does not see doctor. Feels getting old.
• No pale stools, dark urine, h/o hepatitis, gall stones (relevant to history, think about pathogenesis).
• Gained weight recently, frequent paracetamol, ibuprofen for headache for years* no h/o jaundice.
• No transfusions, no risky sexual behaviour, tattoo in Bali 20 years ago, had flu, terrible trip (may have had an acute infection at the time e.g. hepatitis).
• Prison for 3 years - IVDU and sharing needles*
• Alcohol: 10 stub/day, more on weekends/friends.
• No bruising, wt. 95kg, BMI 40 (obesity), no jaundice. (What are the risk factors for developing liver disease?).
• Abdomen: 2 spider naevi (what are they/how do you examine?), no organomegaly (liver, spleen, lymph nodes not enlarged), genitalia normal*
Liver enzymes: • AST = 65 U/l (<40) • ALT = 100 U/I (<45) • ALP = 70 U/I (40-110) • GGT = 110 U/I (<50) • Bilirubin = 23 umol/L (<20) • Albumin = 32 g/L (33-47)
Age, gender, weight (i.e. obese)?
HPC:
• Onset - how long have you been fatigued? Initiating factor?
• Character - worse at a particular time?
• Alleviating factors?
• Timing - experienced before? Constant or intermittent? How long does it last?
• Exacerbating factors?
• Severity?
• Associated symptoms?
• Effect on lifestyle?
• How long have you been trying to conceive? Problems in the past?
- Yellow skin/eyes, pale stools, dark urine?
- Any recent travel/illness?
- Past travel - illness/risky behaviours e.g. sexual, tattoos etc?
- Sexual history - 4Ps.
- Prison?
- IVDU/sharing needles?
- Weight loss, low energy, loss of appetite?
- Weight gain, hair loss, dry skin, cold intolerance?
- Dyspnoea/on exertion, chest pain, weakness, melaena/haematemesis?
- Polyuria, polydipsia?
- Depressed mood/irritable, loss of interest in hobbies, worthlessness, suicidality?
PMHx:
• Past medical history of hepatitis, gallstones, cancer, diabetes etc?
PSHx:
• Any recent surgeries or transfusions?
Medications:
• Any regular medications e.g. paracetamol, NSAIDs etc?
Allergies:
• Agent, reaction, treatment?
Immunisations:
• E.g. Fluvax, pneumococcal?
• Travel vaccines.
FHx:
• Family history of any liver problems, cancer, diabetes etc?
SHx: • Background? • Occupation? • Education? • Religion? • Living arrangements? • Smoking? • Nutrition? • Alcohol/recreational drugs? • Physical activity?
Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?
Perform a physical examination on this patient.
- Introduction, explanation, consent, wash hands. Patient properly positioned lying flat, chest and abdomen exposed.
- General inspection: may be confused/drowsy (liver disease/encephalopathy), colour (jaundice), habitus - cachectic (malignancy/cirrhosis) or obese (fatty liver), muscle wasting, distended abdomen. May be in pain.
3. Vital signs: • HR • RR • BP • Temp • O2 sats, BGL, BMI.
- Hands:
• Palms: warm/cool, sweaty/dry, erythema (chronic liver disease), pallor of creases, Dupuytren’s contracture (affecting ring finger in alcoholism), tremor (alcoholism), hepatic flap (arms stretched out and wrists extended for 15 sec).
• Nails: clubbing (chronic liver disease), CRT, leuconychia (white nails in hypoalbuminaemia), Muehrcke’s lines (transverse white lines in hypoalbuminaemia).
• Arms: bruising/petechiae, scratch marks (cholestatic jaundice, primary biliary cirrhosis), spider naevi (cirrhosis). - Face:
• Eyes: xanthelasma (primary biliary cirrhosis), scleral jaundice, conjunctival pallor.
• Cheek: parotid gland enlargement (ask patient to clench teeth - enlarged gland is felt behind the masseter and in front of the ear - feature of alcoholism).
• Mouth: angular stomatitis (deficiency of iron, folate and B12), alcohol on breath, fetor hepaticus (sweet smell of breath - hepatocellular damage), dentition/dentures.
• Tongue: leukoplakia, glossitis (deficiency of iron, folate and B12), hydration. - Neck/chest:
• Gynaecomastia in males (chronic liver disease/medication).
• Spider naevi (up to 3 can be found in normal patients).
• Lymphadenopathy. - Abdomen:
• Inspection - scarring, striae, abdominal distension (ascites), prominent veins (caput medusa), abnormal skin pigmentation, pulsations or visible masses.
• Palpation - light and deep (tenderness - rebound, guarding, rigidity), hepato/splenomegaly.
• Percussion - liver span, ascites. Shifting dullness, fluid thrill.
• Auscultation - bowel sounds, friction rubs, bruits, venous hums (portal HT).
• Genital examination.
8. Legs: • Bruising/muscle wasting. • Oedema. • Clubbing, CRT. • Peripheral pulses.
What is your provisional diagnosis and differential diagnoses?
• Provisional diagnosis: Hepatitis C chronic (gradually worsening, just fatigue - no acute features. No sudden fever, no jaundice).
• DDx:
- Hepatitis chronic - HBV, HCV, autoimmune.
- Alcohol related disease (chronic alcoholic liver damage possible).
- Drug (paracetamol) related hepatic injury.
- Liver injury from alternative or herbal medicine.
- Obesity - Non alcoholic fatty liver.
- Malignancy.
- Hypothyroidism.
- Anaemia.
- Diabetes.
- Depression.
What investigations would you carry out on this patient?
- FBC.
- U+Es.
- LFTs.
- Coagulation studies.
- HCV serology.
- HBsAg.
- HIV.
- USS abdomen.
- Fe studies - haemochromatosis.
- TFTs.
- Anti-HCV antibodies confirms exposure.
- HCV-PCR confirms ongoing infection/chronicity.
- Liver biopsy if HCV-PCR is +ve to assess liver damage and need for treatment.
What treatment does this patient require?
Patient education is very important:
• Talk and document concerns.
- You have told me things in confidence but there are a few things that may be of concern.
- Would be good to do some tests just to check things are fine.
- If you are trying to have a baby, there is a small risk - be cautious (low transmission sexually).
• Blood tests - need to explain what the test is for and what will happen if the results are positive (ramifications).
• Long term issues - be up front with patient.
- HCV.
- Alcohol abuse - worsening problem.
- Pregnancy.
• Gastroenterologist - involved with him and his wife.
• Regular follow-up.
- Avoid alcohol/drugs.
- Anti-viral therapy - studies demonstrate that treating at an earlier stage of disease is associated with improved outcomes compared with waiting for more advanced disease to develop.
- Liver transplant if cirrhosis.
