Week 3 - Tired, lethargy, feeling low

Question 1

Ms. Jodie Law, DOB 1/1/86 - age 29. Tired, lethargy, feeling low - ‘can’t cope no more’.

Take a history of this patient.

HPC:
• Worsening tiredness for >4 weeks ‘but I’m not moving anywhere fast’.
• Poor sleeping patterns: falling asleep at about 1am, then falling asleep on the couch most afternoons. Snores a lot.
• Recently URTI, dry cough now, no chest pain. Yellow sputum settled.
• PMHx: Asthma, no puffers now, they don’t work.
• Left lower lobe pneumonia, hypothyroidism, overweight, fat baby.
• Recent leg wound not healing - family h/o diabetes.
• Class IV Mallampati score (sleep apnoea).
• Headache, constipation, oligomenorrhoea, dry skin, weight 112kg, height 167cm.

Answer 1

Age, gender, weight (i.e. obese), ATSI?

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?

• Cold intolerance, apathy, dry skin/hair, constipation, weight gain, weakness, voice change, heavy periods?
• Depressed mood/irritable, loss of interest in hobbies, worthlessness, suicidality?
• Polyuria, polydipsia?
• Dyspnoea/on exertion, chest pain, weakness, melaena/haematemesis?
• Snoring, daytime sleepiness?
• Recent illness?

PMHx:
• Past history of any thyroid problems, diabetes, anaemia, mental health etc?

PSHx:
• Past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of any thyroid problems, diabetes, anaemia, mental health 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, change in bowel habit?
• UG - dysuria, polyuria, nocturia, haematuria, 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?

Question 2

Perform a physical examination on this patient.

Answer 2

• Examination covering hypothyroidism (e.g. hyporeflexia), diabetes (e.g. acanthosis nigricans) and anaemia (e.g. pallor) - see notes.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Sleep apnoea.
• DDx:
- Hypothyroidism.
- Diabetes.
- Anaemia.
- Depression.
- PCOS.
- CKD.
- Obesity
- Asthma.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC.
• Iron studies.
• U+Es.
• TFT.
• eGFR.
• LFT.
• HbA1c.
• FSH, LH.
• Lipids.
• K10.
• Polysomnography
• Spirometry.

Question 5

What treatment does this patient require?

Answer 5

• Multiple co-morbidities/issues affecting her health.
• Need to address issues in order of priority.
• See her again in 2-3 days - doctor/patient relationship, compliance, do not want to lose her to the system.
• Involve her family, social worker.
• Indigenous liaison officer (ILOA) - assist with issues such as income, transport e.g. bus.

Question 6

Outline the patient’s problem list.

Answer 6

• Fatigue - quality of life.
• Ability to look after children.
• Non compliance with medications (hypothyroidism, asthma - due to income etc.)
• Alcohol consumption.
• Medical conditions - ?PCOS, ?OSA, ?Depression, ?Diabetes.
• Social issues e.g. verbal abuse.
• Low mood (depression).