Week 3 - Infertility and tiredness Flashcards

1
Q

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)
A

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?

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2
Q

Perform a physical examination on this patient.

A
  1. Introduction, explanation, consent, wash hands. Patient properly positioned lying flat, chest and abdomen exposed.
  2. 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.
  1. 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).
  2. 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.
  3. Neck/chest:
    • Gynaecomastia in males (chronic liver disease/medication).
    • Spider naevi (up to 3 can be found in normal patients).
    • Lymphadenopathy.
  4. 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.
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3
Q

What is your provisional diagnosis and differential diagnoses?

A

• 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.

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4
Q

What investigations would you carry out on this patient?

A
  • 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.
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5
Q

What treatment does this patient require?

A

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.
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