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CPC TERM 3 > Week 5- Fatigue > Flashcards

Week 5- Fatigue Flashcards

1
Q

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.
-20units of alcohol per week (should only be 14)
• 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* (reactive lymphadenitis from cat scratch)
• 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.

A

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? Sleep hygiene (amount)
• 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?
-Dizziness/Palpitations/Headaches?
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?

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2
Q

Perform a physical exam on the patient
-Normal vitals
-Lymphadenopathy-> 5 nodes elevated
-

A
  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
-Looking for signs of alcoholism-> dupytrens contracture
  1. Face:
    • Eyes - conjunctival pallor, scleral jaundice.
    • Mouth - hydration, cyanosis, pallor, signs of inflammation/infection, enlarged tonsils, ulcers, gum hypertrophy/bleeding, petichiae
    -Enlarged parotids/malar flush–> alcoholism
  2. Neck:
    • Cervical lymph nodes.
  3. 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.
  1. CVS/RS
    • Systolic flow murmurs, heart failure.
    • Pleural effusions, chest infections.
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3
Q

Provisional and ddx

A 
• Provisional diagnosis: Chronic lymphocytic leukaemia. 
• DDx: 
- Viral/chronic infections. 
- TB. 
- Leukaemia. 
- Lymphoma. 
- Malignancy. 
- Anaemia. 
- Hypothyroidism. 
- Diabetes. 
- Depression. 
- CCF. 
- CKD. 
- Sleep apnoea.
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4
Q

What IX would you perform

-

A
  • FBC.
  • WCC differential count.
  • Peripheral blood smear.
  • Flow cytometry.
  • Immunophenotyping.
  • Inflammatory markers.
  • Immunoglobulins - hypogammaglobulinaemia.
  • Aspiration cytology.
  • Ultrasound/CT.
  • Trepine biopsy.
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5
Q

What tx is required

-Has CLL

A

• 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.
-Test for viral infection–> immunosuppressants can reactivate latent viral infections

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CPC TERM 3 (6 decks)

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