Week 5 - Fatigue

Question 1

Mr. M.S. is a 67-year-old man. He was contacted and asked to come in to see his GP to discuss a blood test result. Bloods were organised as he was feeling fatigued the past few weeks.

Take a history of this patient.

HPC:
• FBC: Hb 120g/L (low), WCC 25x10^9/L (high), platelets 185x10^9/L (low).
• Fatigue, tired for weeks, dyspnoea.
• Recurrent infections the past winter - not usual.
• Hypertension, T2DM, IHD.
• No fever, easy bruising, weight loss or gum bleeding* (why were these questions asked?)
• No suggestion of chronic bleeding, GI blood loss etc.
• No new pets, no cats* (what is the significance?)
• O/E: pallor, neck bilateral lymphadenopathy >5 nodes on each side (submandibular, tonsillar, post. triangle). Non-tender 2x2cm.
• Spleen just tipped when lying on right side. No bony tenderness.

Answer 1

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?

Abnormalities of white cells:
• Recurrent infections?
• Fever or jaundice?
• Mouth ulcers?
• Gum bleeding?

Lymphoma:
• Lymph node enlargement?
• Malaise, loss of weight, fever, tiredness?

Haematological system:
• Bruise easily?
• Fever or shivers/shakes?
• Difficulty stopping a small cut from bleeding?
• Any lumps under arms, neck or groin?
• Blood clots in legs or lungs?

Myeloma:
• Recurrent infections?
• Bone pain?
• Symptoms of hypercalcemia?
• Enlargement of tongue?

• Weight loss, loss of appetite?
• Dyspnoea/on exertion, chest pain, weakness, melaena/haematemesis?
• Weight gain, hair loss, dry skin, cold intolerance?
• Polyuria, polydipsia?
• Depressed mood/irritable, loss of interest in hobbies, worthlessness, suicidality?
• Recent travel, night sweats, haemoptysis?

PMHx:
• Past history of any blood disorders, anaemia, cancer etc?

PSHx:
• Past surgeries?

Medications:
• Any regular medications e.g. NSAIDs, blood thinners.

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?
• Travel vaccines.

FHx:
• Family history of any blood disorders, anaemia, cancer etc?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs? 
• Physical activity?

Systems Review:
• General - weight change, fatigue, weakness, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea/on exertion, cough/sputum?
• GI - vomiting, diarrhoea, change in bowel habit?
• UG - dysuria, urine output?
• CNS - headaches, nausea, blurred vision?
• ENDO - cold/heat intolerance, swelling in neck, increased thirst/hunger?
• MSK - sore joints/muscles, rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: wasting, pallor, plethora, jaundice, scratch marks, bruising.
3. Vital signs:
   - HR - tachycardia.
   - RR - tachypnoea.
   - BP - hypertension.
   - Temp - febrile.

4. Hands/arms:
• Warm/cold, dry/sweaty, pallor.
• Koilonychia, pallor of nail beds.
• CRT, clubbing.
• Gout, purpura (petechiae/ecchymoses).
• Epitrochlear nodes, axillary nodes

5. Face:
   • Eyes - conjunctival pallor, scleral jaundice.
   • Mouth - hydration, cyanosis, pallor, signs of inflammation/infection, enlarged tonsils, ulcers, gum hypertrophy/bleeding.
6. Neck:
   • Cervical lymph nodes.
7. Back:
   • Check for bony tenderness or pathological fractures. Tap over spine, check sternum, clavicle and shoulders by pushing them towards each other.

8. Abdomen:
• Inspection - visible masses.
• Palpation - hepatosplenomegaly, masses, verbalise would palpate inguinal lymph nodes.
• Percussion: fluid.
• DRE.

9. Legs:
• Temperature.
• Bruising.
• Purpura.
• Pigmentation.
• Scratch marks.
• Ulcers.
• Oedema.
• CRT.

10. CVS/RS
    • Systolic flow murmurs, heart failure.
    • Pleural effusions, chest infections.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Chronic lymphocytic leukaemia.
• DDx:
- Viral/chronic infections.
- TB.
- Leukaemia.
- Lymphoma.
- Malignancy.
- Anaemia.
- Hypothyroidism.
- Diabetes.
- Depression.
- CCF.
- CKD.
- Sleep apnoea.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC.
• WCC differential count.
• Peripheral blood smear.
• Flow cytometry.
• Immunophenotyping.
• Inflammatory markers.
• Immunoglobulins - hypogammaglobulinaemia.
• Aspiration cytology.
• Ultrasound/CT.
• Trepine biopsy.

Question 5

What treatment does this patient require?

Answer 5

• Referral to haematologist/oncologist.
• If suspect leukaemia → start treatment - do not need to biopsy (peripheral smear is fine). Monitor and see if improve.
• Drugs - fludarabine + cyclophosphamide + rituximab.
• Steroids - help autoimmune haemolysis.
• Radiotherapy - helps treat lymphadenopathy and splenomegaly.
• Supportive care - transfusions, IV human immunoglobulin if recurrent infection.