Week 3- Tired, lethargy, low mood

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.
-Sleep apnoea score of 16= requires sleep study

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 an exam

• Dry hair and skin
• Not pale or jaundiced
• BP; 170/85
• BSL; 12
• Acanthosis nigricans in arms
• Poor dental hygiene
• Hung up ankle jerk reflex

Answer 2

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

Question 3

What is your provisional and differential dx

Answer 3

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

Question 4

What ix would you perform

Answer 4

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

Question 5

What treatment does the 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- arrange clinic car pick up
• Involve her family, social worker.
• Indigenous liaison officer (ILOA) - assist with issues such as income, transport e.g. bus.
-Assess risk of children
-Begin with addressing fatigue and low mood as that is why she presented, then move onto treating hypothyroidism and metabolic syndrome
-Assess depression and begin non-pharmacological tx
-GP intervention for alcohol issues
-Organise pharmacy home visits
-USS for liver and ovaries
-Involve dietician and diabetes educator

Question 6

What is the patients problems list

Answer 6

• Fatigue - quality of life.
-Sleep disturbance and arrange sleep study
-Domestic chaos and distress
-Binge pattern of drinking (alcohol)
• Ability to look after children/relationship with children
-Socially isolated
• Non compliance with medications (hypothyroidism, asthma - due to income etc.)
• Metabolic medical conditions - ?PCOS, ?OSA, ?Depression, ?Diabetes.
• Low mood (depression)–> probable risk of self-harm
-Lack of education/health literacy
-BSL
-Morbidly obese–> lifestyle change/diet
-Financial problems
-Transport to health care services
-Hypothyroidism