Tiredness

Question 1

Why does Mina come in to see the GP?

Answer 1

feels tired all the time
cannot understand why
feels like being surrounded by fog

Question 2

How has the tiredness been impacting Mina’s life?

Answer 2

has to change her working patterns because the later it gets the less productive she is

takes afternoon naps on the weekend

Question 3

What does her lifestyle look like?

Answer 3

vegetarian
but quality of diet depends
works hard at staying fit - put on weight over the summer

Question 4

Any other symptoms?

Answer 4

skin is dry

Question 5

Family history?

Answer 5

sister went to the doctor for tiredness but was diagnosed with vitamin D deficiency

Question 6

What does the GP suggest?

Answer 6

MOT
simple blood tests
look at lifestyle to see if there are any contribution factors

Question 7

What is the difference between tiredness and fatigue?

Answer 7

Fatigue is when the tiredness is often overwhelming and isn’t relieved by sleep and rest.

Question 8

What are the 10 medical reasons for feeling tired?

Answer 8

Anaemia
Sleep apnoea
Underactive thyroid
Coeliac disease 
Chronic fatigue syndrome 
Diabetes 
Glandular fever
Depression
Restless legs
Anxiety

Question 9

What is the most common medical reasons for feeling run down?

Answer 9

Iron deficiency anaemia

Question 10

Who is prone to anaemia?

Answer 10

Women with heavy periods

Pregnant women

Question 11

What are less common causes of anaemia?

Answer 11

Ulvers

NSAIDS

Question 12

What is sleep apnoea?

Answer 12

condition where your throat narrows or closes during sleep and repeatedly interrupts your breathing

Question 13

What does sleep apnoea result in

Answer 13

loud snoring and a drop in your blood’s oxygen levels

The difficulty in breathing means you wake up often in the night and feel exhausted the next day

Question 14

Who is sleep apnoea most common in?

Answer 14

overweight middle-aged men

Drinking alcohol and smoking makes it worse

Question 15

What is an under-active thyroid?

Answer 15

Too little thyroid hormone (thyroxine) in your body

This makes you feel tired

Question 16

What are other symptoms of having an under-active thyroid?

Answer 16

Weight gain

Aching muscles

Dry skin

Question 17

What is coeliac disease?

Answer 17

lifelong disease caused by the immune system reacting to gluten

Question 18

What are the symptoms of coeliac disease?

Answer 18

tiredness, diarrhoea, bloating, anaemia and weight loss

Question 19

What is chronic fatigue syndrome also known as?

Answer 19

myalgic encephalomyelitis, or ME

Question 20

What is chronic fatigue syndrome?

Answer 20

severe and disabling fatigue that goes on for at least 4 months.

There may be other symptoms, such as muscle or joint pain.

Question 21

What is glandular fever?

Answer 21

common viral infection that causes fatigue, along with fever, sore throat and swollen glands

Question 22

What is restless legs?

Answer 22

overwhelming urge to move your legs, which can keep you awake at night

Question 23

What is GAD?

Answer 23

Generalised anxiety disorder

Question 24

What percentage of GP consultations are for fatigue?

Answer 24

7%

Question 25

To the nearest 10%, what percentage of patients who present to a GP with fatigue have a diagnosis made?

Answer 25

66%

Question 26

To the nearest 10%, what percentage of patients who present to a GP with fatigue have a condition that is detected on blood tests?

Answer 26

<10%

Question 27

Give other possible causes of fatigue?

Answer 27

``` Cancer Autoimmune disease Side effects of medication Diabetes Vitamin D deficiency Eating Disorder Fibromyalgia Pregnancy ```

Question 28

What to BMJ Best Practice say are causes of fatigue?

Answer 28

Chronic heart failure TB Stroke Addison's LOTS

Question 29

Suggest 4 differentials for Mina?

Answer 29

Hypothyroidism Vitamin D deficiency Anaemia Diabetes

Question 30

What suggests that Mina has hypothyroidism?

Answer 30

``` Low metabolic rate Cold intolerance Weight gain Constipation Dry skin Slow heartbeat ```

Question 31

What tests would we conduct in Mina?

Answer 31

``` FBC U&E Vitamin D Thyroid function tests HbA1c ```

Question 32

What were the results of Mina's TFTs?

Answer 32

TSH high T3/T4 low Primary hypothyroidism

Question 33

What does Mina have?

Answer 33

Hashimoto's

Question 34

Describe what happens in Hashimoto's

Answer 34

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)

Question 35

What are the strategies to sift out the physical causes of tiredness?

Answer 35

# Define the type of tiredness Why did the patient present with this? Screen for red flags Explore and psychosocial triggers Examine the patient (pulse, BP and BMI) The plan

Question 36

What are red flags when it comes to tiredness?

Answer 36

Lymphadenopathy Weight Loss Specific malignancy features focus on: lung, breast, colon, upper GI and Gynae Join pains Focal neurology Infective symptoms e.g. glandular fever and lyme

Question 37

What could be psychosocial triggers?

Answer 37

``` Mood Drugs and Alchohol Family Work Money ```

Question 38

What questions with someone with hypothyroidism ask their doctor?

Answer 38

Why did I get an underactive thyroid? • Will I get better? • Do I need treatment? • What's the best treatment for me? • Will I need to have treatment for the rest of my life? • What are the side effects of treatment? How can I cope with them? • Should I change what I eat? • What are the chances that someone else in my family will get an underactive thyroid? Does it run in families? • How will my treatment be managed if I wish to get pregnant (women)?

Question 39

How would you explain to a patient the action of thyroxine?

Answer 39

Helps to control how fast your body makes and uses energy from food

Question 40

What are the symptoms of hypothyroidism?

Answer 40

``` Feeling tires or depressed Thinking more slowly or less clearly than usual Having dry skin Putting on weight Feeling the cold more than usual Having constipation Irregular periods ```

Question 41

What might someone with hypothyroidism notice over many years?

Answer 41

``` Dry, flaky skin Coarse hair or hair loss Put on weight even though caloric intake is the same Feel depressed Feel sluggish Have a hoarse voice ```

Question 42

How is hypothyroidism treated?

Answer 42

Levothyroxine replacement for life One a day on an empty stomach (100-150mg) Start on low dose then increase

Question 43

What might happen if you take too much thyroxine?

Answer 43

Atrial fibrilaton | Bone thinning

Question 44

What can cause hypothyroidism?

Answer 44

``` Autoimmune 'Hashimoto's' Radioactive iodine treatment Thyroid surgery Antithyroid drugs Lithium drugs Cough medicines Health foods in excess Malfunction of the pituitary gland Radiation for head and neck cancers ```

Question 45

What is mild thyroid failure or subclinical hypothyroidism?

Answer 45

Very slight hypothyroidism No obvious symptoms Raised TSH and normal FT4

Question 46

What should happen if you get pregnant?

Answer 46

Increase dose by 25-50mcg | TFTs asap

Question 47

What can trigger graves and hashimotos?

Answer 47

Stress Pregnancy Genetics

Question 48

What is the more appropriate name for hashimotos?

Answer 48

chronic immune thyroiditis

Question 49

How can hashimotos be detected clinically?

Answer 49

Presence of antibodies Rise in TSH Low blood thyroxine

Question 50

Give two ways that hypothyroidism can present

Answer 50

Goitrous autoimmune thyroiditis | Atrophic autominnue thyroiditis

Question 51

What are the main features of goitrous autoimmune thyroiditis?

Answer 51

Progressive infiltration of white cells enlarges the thyroid Goitre formation Worsened by increase in dietary iodine

Question 52

What are the main features of atrophic autoimmune thyroiditis?

Answer 52

most common form thyroid gland shrinks with progressive loss of tissue antibodies block the TSH receptors