Mina Flashcards
(43 cards)
What does Mina’s patient profile tell us?
Worried about what is causing her tiredness, researched online
Mina flies frquently to scout out the latest trends in fashion
Flying is making her skin dry
Enjoys yoga several times a week, finds this more difficult with her fatigue
Drinks multiple cups of coffee a day to stay alert and focussed at work
Feels cold, always wears a scarf
Received indoor plant as a gift
What does Mina talk about in her Case video?
25/08/1988
Feels tired all the time
Feels like she’s surrounded by fog
The later the day gets, the more her tiredness increases and affects her work
Normally gets 6-7 hours of sleep, now struggling to get up in the mornings and taking afternoon naps on weekends
Buyer for Harrods - involves a lot of travelling (quite sure work is not her reason for tiredness)
Not stressed - sees girlfriend on weekends
Lives alone in Sloane Square
Vegetarian - diet fluctuates depending on workload
No alcohol, no smoking, no recreational drug use
Airplane skin - dry skin from flying
Sister = tiredness = Vit D deficiency
Mother = tiredness = diabetic
Working out extra hard recently to shed extra weight she gained over summer
What examinations does the doctor carry out on Mina over video?
Fit bit - HR = 55 (she says that’s good for her)
Eyes / pupils normal
No gland swelling
What does the doctor tell Mina in the case video?
Many reasons for tiredness
Wants to do a blood test to look for common causes
Wants to look at her lifestyle to see contributing factors and implement changes
Another consultation after the blood test
What’s the difference between tiredness and fatigue?
Tiredness = relieved by rest and sleep Fatigue = overwhelming tiredness that isn't relieved by rest and sleep
What are 10 medical reasons for feeling tired?
Anaemia Sleep apnoea Underactive thyroid Coeliac disease Chronic fatigue syndrome Diabetes Glandular fever Depression Restless legs Anxiety
What is anaemia and how can it cause tiredness?
Most likely iron-deficiency anaemia
Low RBC count
Mainly affects women with heavy periods or during pregnancy
In others, may be due to ulcers or NSAIDs
Or haemochromatosis = iron overload
Can lead to tiredness
What is sleep apnoea and how can it cause tiredness?
Throat narrows or closes during sleep and repeatedly interrupts breathing
Results in loud snoring and a drop in blood’s oxygen levels
Constant waking up at night and lack of O2 = exhaustion during the day
Most common in overweight, middle aged men (drinking and alcohol makes it worse)
What is an underactive thyroid and how can it cause tiredness?
Too little thyroid hormone (thyroxine)
Likely to put on weight and have aching muscles and dry skin
Most common in women
What is coeliac disease and how can it cause tiredness?
Immune system reacting to gluten
What is chronic fatigue syndrome and how can it cause tiredness?
AKA myalgic encephalomyelitis, or ME
Severe and disabling fatigue that goes on for at least 4 months
What is diabetes and how can it cause tiredness?
Body’s inability to control BGL using insulin
What is glandular fever and how can it cause tiredness?
Common viral infection that causes fatigue
Usually in teenagers and young adults
What is depression and how can it cause tiredness?
Constant low mood / anhedonia
Can stop you falling asleep or cause you to wake up early
What are restless legs and how can it cause tiredness?
Overwhelming urge to move your legs, which can keep you awake at night
May have unpleasant crawling sensation or deep ache in legs
Legs may jerk spontaneously
Disrupted sleep quality
What is anxiety and how can it cause tiredness?
Constant uncontrollable feelings of anxiety that affect their daily life
Affects women slightly more than men, feeling worried and irritable can lead to tiredness
What percentage of people present to the GP with fatigue?
What percentage of patients who present to a GP with fatigue have a diagnosis made?
What percentage of patients who present to a GP with fatigue have a condition that is detected on blood tests?
7%
2/3
<10%
What are some possible causes of fatigue?
Sleep apnoea Hypothyroidism Anaemia Coeliac disease Chronic fatigue syndrome Diabetes Glandular fever Depression Restless legs Anxiety Cancer Medications Diabetes Vit D deficiency Chronic pain - fibromyalgia Autoimmune - cushing's Malnutrition - eating disorders Pregnancy Arthritis / Rheumatoid Lupus Heart failure Infection Restless legs CKD
What is the differential diagnosis for Mina’s fatigue?
Hypothyroidism - dry skin, fatigue
Anaemia - fatigue, vegetarian
Vitamin D deficiency - fatigue, vegetarian, family history
Diabetes - family history
More history about Mina: Put on a stone since summer She rarely gets ill, last time she had a virus was years ago Good mood No stiffness or aches No periods - coil BC No much change in bowel habits, maybe constipated lately Feels cold - has to put on more layers
Using this, what are the top 2 differentials?
1. Hypothyroidism: Fatigue Dry skin Feels cold - has to put on more layers Constipation
- Anaemia
Fatigue
Vegetarian
Feels cold - has to put on more layers
What would be less likely for Mina?
Sleep apnoea - no snoring / waking up at night
Glandular fever - no high temperature
Lupus - no rash
Pregnancy - not pregnant
Pick 4 relevant blood tests to order for Mina and why:
FBC (Full blood count) U&E (Urea and electrolytes) Vitamin D TFT (thyroid function tests) CRP (C-reactive protein) Coeliac screen Autoimmune screen EBV serology HbA1C
TFT - check for hypothyroidism
FBC - check for anaemia, infection
Vit D - check for Vit D deficiency due to family history
U&E
[Autoimmune screen - specific panel of tests = although these tests are v. specific and can have you going down the wrong path]
CRP is raised in infections and malignancies
Mina is found to have a goitre - swollen smooth thyroid gland
Her blood tests show:
TSH 18 mU/L
Free T4 1.2 pmol/L
Free T3
What is the diagnosis for Mina?
Hypothyroidism Dry skin Weight gain Feeling cold Fatigue
Blood tests show high TSH levels but low T3 and T4 levels = primary hypothyroidism
“An under-active thyroid often occurs when the immune system, which usually fights infection, attacks the thyroid gland. This damages the thyroid, which means it’s not able to make enough of the hormone thyroxine, leading to the symptoms of an under-active thyroid. A condition called Hashimoto’s disease is the most common type of autoimmune reaction that causes an under-active thyroid.” - NHS
What is the mechanism that causes immune cells to attack thyroid cells in Hashimoto’s disease?
APC uses MHC-II molecule to present thyroid antigens to T cells
Cytotoxic T cells and B cells go damage the thyroid cells
APCs process antigens presenting them to T-cells
In hashimoto’s self-antigen is presented on MHC II to TCR
Look at POM notes (Immune tolerance)
