Week 4- Lethargy, DOE, Swelling of ankles

Question 1

A 63-year-old woman presents with a 1 year history of increasing lethargy and a more recent onset of dyspnoea on exertion, ankle swelling and difficulty walking.

Take a history of this patient.

• Increasing lethargy, dyspnoea, oedema - 1 year (chronic problem).
• Difficulty walking - weakness and unsteadiness - 2 weeks- needs to sit down to rest for half an hour
-Sleeps for 7-8 hrs continuously
• Initially treated with iron tablets - did not improve.
• Increasing lethargy, dyspnoea, ankle swelling.
-Feels lightheaded when standing up quickly (postural hypotension)
-History of arthritis
- Lethargy, dyspnoea - decreased oxygen - lungs functioning over the capacity to provide oxygen to body. Ankle swelling suggestive of cardiac failure.
• Palpitations, chest pain on exertion, relieved on rest.
- Palpitations in response to tissue ischaemia, sympathetic stimulation, increased cardiac load. Chest pain on exertion - severe sign of myocardial ischaemia, similar to angina, due to severe anaemia. Relieved on rest - not due to any permanent block.
• Fever sometimes. Loss of appetite, some loss of weight.
- Fever (some immunosuppression - decreased WBCs), loss of appetite/weight (deficiency disorder, malignancy).
• History of hypothyroidism - takes thyroxine, history of osteoarthritis, takes NSAID (meloxicam)
- Hypothyroidism common in older age, also causes anaemia. Thyroid hormones necessary for many metabolic functions. NSAIDs - cause of bleeding, gastritis.
-Has a family history of stomach cancer, T2DM, Reynauds disease and heart conditions
-Social drinker, non smoker, balanced diet
-Loss of 10kg unintentionally in last yr
-Notices bruises quite easily on limbs
-Appendix removed at 22, 2 previous c-section
-Noticed her eyes and skin are more yellow
-Noticed her memory is failing

Answer 1

HPC: 
• Onset - how long have you been lethargic? Initiating factor? 
• Alleviating factors? 
• Timing - experienced before? Constant or intermittent? How long does it last/worse at a particular time? 
• Exacerbating factors? 
• Severity? 
• Associated symptoms? 
• Effect on lifestyle?

• Tiredness, weakness, dyspnoea, fatigue, postural dizziness.
• Bleeding from the bowel or vomited any blood?
• Black bowel motions?
• Past stomach ulcers or inflammation of the bowel or previous bowel operations?
• Arthritis tablets or blood thinning tablets?
• Recent operation or procedure (blood loss)?
• Heavy periods?
• Diet? Alcohol?
• Iron or vitamin supplements?
• Kidney problems or chronic severe arthritis (anaemia of chronic disease)?
• Have you ever needed a blood transfusion?
• Have you been generally unwell or had problems with recurrent infections or ulcers?
• Family history of anaemia?
• Bruise easily or fever/infections?
• Cold intolerance, apathy, dry skin/hair, constipation, weight gain, weakness, voice change, heavy periods?
• Weight loss, fatigue, loss of appetite?
• Dyspnoea, chest pain, palpitations, orthopnoea/PND?

PMHx:
• Past history of any heart problems, anaemia, thyroid problems, cancer, autoimmune issues?

PSHx:
• Past surgeries? i.e. resection of stomach/terminal ileum.

Medications:
• Any regular medications? i.e. NSAIDs, thyroxine.

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of any heart problems, anaemia, thyroid problems, cancer?

SHx: 
• Background? 
• Occupation? 
• Education? 
• Religion? 
• Living arrangements? 
• Smoking? 
• Nutrition? i.e vegan 
• Alcohol/recreational drugs? i.e. excessive alcohol intake. 
• 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?

Question 2

Perform a physical exam on the patient
• She bruises easily, pale, mild jaundice.
- Bruises easily - some problem with haemostasis (decreased platelets). Mild jaundice - liver problem or breakdown of RBC.
• Stomatitis, glossitis.
- Loss of epithelial integrity due to cytochrome enzymes (common in both IDA and MBA when severe).
• PNS: 4/5 lower limb power, tone in lower limb increased, sensation reduced in all aspects except pain in lower legs, Romberg +ve (used for detecting drunken people), reflexes decreased, Babinski +ve
-BMI= 26
-Conjunctival pallor and scleral jaundice
-Angular stomatitis
-Buccal mucosa is pale
-Ejection systolic murmur in aortic murmur
-JVP elevated
-Pitting edema to mid calf

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: weight loss, pallor, mild jaundice, bruising, racial origin (pernicious anaemia).

3. Vital signs: 
• HR - tachycardic. 
• RR - tachypnoeic. 
• BP - postural variation. 
• Temp. 
• O2 sats.

4. Hands/arms:
   • Warm/cold, dry/sweaty, pallor in palmar creases.
   • CRT, koilonychia, pallor of nail beds.
   • Arthropathy.
   • Splinter haemorrhages (autoimmune vasculitis).
   -Bruising/petechiae/purpura
   -Proximal myopathy
   -Epitrochlear/axillary lymph node enlargement
5. Face:
   • Eye - conjunctival pallor, scleral jaundice.
   • Mouth - hydration, pallor (buccal mucosa), atrophic glossitis, chelitis, angular stomatitis, ulcers/bleeding.

6. Neck: 
• Carotids - volume/character. 
• JVP (may be raised). 
• Thyroid examination. 
• Lymphadenopathy.

7. Abdomen:
   • Hepatosplenomegaly.
   • Rectal examination.
8. Legs:
   • Bruising.
   • Peripheral oedema.
9. CVS:
   • Systolic flow murmurs, signs of CCF (pulmonary oedema - bibasal creps).
10. NEURO:
    • Peripheral neuropathy (B12 deficiency) - sensory - light touch, pain, proprioception, vibration, reflexes.
    -Cranial nerves

Question 3

Provisional and ddx

Answer 3

• Provisional diagnosis: Megaloblastic Anaemia due to VB12 def..
• DDx:
- Pernicious anaemia- fam history and peripheral neuropathy
-Iron def. anaemia
-Malignancy, aplastic anaemia.
-Infective endocarditis leading to valvular disease
-Bone marrow failure-Refractory anaemia.
- GI bleed.
- CCF.

• Anaemia with jaundice in later age - MBA, haemolytic, marrow disorders.

Question 4

What ix would you like to perform

• Hb 62 (low)
• Plt 31 (low) norm 140-400
• WCC 3.7 (low)
• VB12 30 (should be more than 210)
• Folate 643 (normal)
• Positive parietal cell and intrinsic factor antibody
• Iron studies are normal
• LFT normal
• Bilirubin is 80
• Conjugated 3 (intravascular hemolysis)
• Echo is normal
• Holotranscobalamin levels

Answer 4

• FBC.
• U+Es.
• LFTs.
• ECG.
• TFTs.
• Iron studies.
• Serum vitamin B12 and folate.
• Peripheral blood smear.
• Antibodies - parietal cells, intrinsic factor.

Question 5

What tx is required

Answer 5

• Assess for an underlying cause (e.g. poor diet, malabsorption) and treat.
• If deficiency due to malabsorption - injection i.e. hydroxocobalamin (B12).
• If deficiency due to diet - oral supplementation.
• Complete workup of heart and bone marrow.
• OT - check out house - rails, replace steps.
• Physiotherapy - rehab.
• Occupational test for driving - memory loss, uncoordinated/unsteady on feet.