Tired All The Time

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FieldsIron Deficiency Anaemia Folate Deficiency Anaemia Haemolytic Anaemia Aplastic Anaemia GI Bleed Hypothyroidism Sideroblastic Anaemia Pernicious Anaemia (B12 Deficiency) Thalassaemia Sickle Cell Disease Low Mood 
Age Premenopausal women and elderly Increases with age Increases with age Any Age Increases with age Mean age 60y Increases with Age Increases with age Often presents in 1st year of life Often presents in 1st year of life Any Age 
Gender F>M M=F M > F M = F M > F F > M M > F M = F M = F M = F M = F 
Typical Presentation A 25 year old women presents to her GP complaining of feeling tired all the time. She has a history of coeliac disease and menorrhagia. A 65 year old man with a history of alcohol excess presents to her GP complaining of feeling tired and depressed. On examination, she appears very underweight. A 15 year old Greek boy with a history of neonatal jaundice develops pallor and jaundice after having a lower respiratory tract infection. He complains of feeling tired all the time. His blood film shows Heinz bodies. A 10 year old boy who has recently completed chemotherapy for acute lymphoblastic leukaemia is brought into haematology clinic with a 1 month history of lethargy. He suffered from 3 cold-like syndromes and numerous nosebleeds in the past 4 weeks. A 65 year old man with a history of peptic ulcer disease visited his GP complaining of several episodes of vomiting blood. He said he felt tired all of the time, and on examination he had pale mucous membranes and was tachycardic and hypotensive A 60 year old woman presents to her GP after recent weight gain despite loss of appetite. She complains of feeling tired and cold all of the time, with recent onset constipation. On examination, she has a swelling in her neck and is hypertensive. A 50 year old man who complains of feeling tired all of the time is investigated in the haematology department. His blood film shows a microcytic anaemia with ring sideroblasts A 60 year old alcoholic male with a family history of gastrectomy presents to his GP complaining of feeling tired all the time. On examination, he is icteric and has a symmetrical polyneuropathy of the lower limb. A 40 year old woman from India who has recently moved to England presents to her GP complaining of feeling tired all the time. She speaks little English, but explains that her parents suffered from the same problem. On examination she is mildly jaundiced with pale mucous membranes. A Greek 6 month old baby is rushed to A&E with jaundice and a swollen abdomen. He has been sleeping more than usual recently. A 18 year old woman presents to her GP complaining of feeling tired all the time. She has a 1 year history of depressive episode and takes 10mg citalopram daily. 
Other Symptoms Few ● Tired all the time ● Depression ● Tired all the time ● Painful swelling of hands and feet ● Tired all the time ● Frequent infections ● Tired all the time (if chronic - see Iron Deficiency Anaemia). ● Medical emergency if acute ● Tired all the time● Depression ● Poor libido ● Constipation ● Weight gain ● Tired all the time ● Tired all the time ● Depression ● Tired all the time ● Frequent infections ● Tired all the time ● Tired all the time ● Depression 
Pain Usually none. Insidious Rare. Insidious Acute, recurrent Acute or chronic Acute or sub-acute Usually none Chronic Often none. Insidious/ Chronic condition Often none. Chronic condition Chronic condition; acute, recurrent crises N/A 
Signs May be none. ●Brittle hair and nails ● Atrophic glossitis ● Angular stomatitis ● Post-cricoid webs ● Koilonychia ● PICA ● Low BMI ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Low BMI ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Signs of alcoholism ● Jaundice ● ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Frequent infections ● Bruising ● Epistaxis ● Bleeding gums ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Signs of hypovolaemia/ shock ● Orthostatic hypotension ● Haematemesis/ malaena/ bloody stools ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Dry hair ● Dry, waxy skin ● Puffy eyes ● Deep voice ● Cold intolerance ● Goitre in Hashimoto’s ● Hypertension ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Glossitis ● Angular stomatitis ● Jaundice ● Symmetrical polyneuropathy ● Dementia ● Visual disturbances ● Low BMI ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Signs of iron overload ● Frequent infections ● Bone deformities ● Splenomegaly ● Slowed growth rates ● Delayed puberty ● Jaundce ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Splenic atrophy by adulthood ● Slowed growth rates ● Delayed puberty● Signs of iron overload ● Jaundice● Pale mucous membranes ● Tachycardia ● Tachypnoea ● No physical signs 
Past Medical History ● Malnutrition●Pregnancy ●Coeliac disease ●Small bowel disease ● Gastrectomy● Hookworm ●Heavy menstruation ● GI bleeds ● Alcoholism ● Malnutrition ● Coeliac disease ● Crohn’s disease ● Tropical Sprue ● Pregnancy ● Chronic haemolytic anaemia ● Malignancy ● Renal dialysis ● DH: phenytoin, trimethoprim, sulphasalazing, methotrexate ● FH ● HX autoimmune conditions ● GP6D deficiency: African, Mediterranean, Middle and Far Eastern origin ● Haemolytic-uraemic syndrome ● TTP ● DIC ● Pre-eclampsia ● Eclampsia ● Infectious mononucleosis ● FH ● Leukaemia ● Falconi’s syndrome ● DH: cytotoxic drugs/ irradiation (chemotherapy, phenytoin, NSAIDs) ● Chemical poisoning: benzene, insecticide, arsenic ● HIV ● Hepatitis ● TB ● Pregnancy ● DH NSAIDs/ aspirin ● H. Pylori infection ● Hx PUD ● Haemorrhoids ● Ulcerative colitis ● Crohn’s disease ● Dyspepsia ● Liver disease ● Alcoholism ● FH ● Hx hyperthyroidism treated with radioablation ● Iodine deficiency ● HX autoimmune conditions ● HX pernicious anaemia/ T1 DM/ Addison’s ● Turner’s syndrome ● Down’s syndrome ● Cystic fibrosis ● PBC ● FH (x-linked) ● HX alcohol excess ● Lead toxicity ● DH isoniazid, chemotherapy, anti-TB drugs ● Irradiation ● FH ● HX autoimmune conditions ● Crohn’s disease ● Gastrectomy ● Alcoholism ● Vegan diet ● Malnutrition ●FH (AR) ● Mediterranean/ Far Eastern origin ● Congestive HF ● Arrythmias ●FH (AR)● Mediterranean origin● HX of sickle crises; dactylitis in childhood, mesenteric ischameia, CNS infarction, AVN of long bones, priapism, acute chest syndrome ● Crises prompted by cold, infections, heavy periods ●Gallstones ● Chronic renal failure ● HX depression ● FH psychiatric conditions ● Stress ● HX loss of appetite 
Bloods ● Blood film: microcytic anaemia: MCV ● Blood film: megaloblastic microcytic anaemia ● Red cell folate: low ● Bloodfilm: normocytic anaemia ● Reticulocytosis ● spherocytosis if autoimmune ● Elliptical cells in hereditary elliptocytosis● Low GP6D possibly with bite cells/ blister cells/ Heinz bodies on film ● Blood film: normocytic anaemia ● Pancytopenia ● Low/ absent reticulocytes ● Blood film: normocytic anaemia ● Blood film: macrocytic normoblastic anaemia ● TSH: high ● T4: low ● TPO antibodies: high ● AST: high ● Blood film: microcytic anaemia with ring sideroblasts (erythroblasts with iron deposited in mitochondria) ● Hypochromia ● Ferritin: high ● Serum iron: high ● TIBC: normal ● Blood film: megaloblastic microcytic anaemia (MCV >110fL) ● Hypersegmented neutrophil nuclei ● Leucopenia and thrombocytopenia ● Serum B12: low ● Folate: low ● Parietal cell autoantibodies/ intrinsic factor antibodies may be present ● Serum bilirubin: high ● Blood film: microcytic anaemia ● High reticulocyte count ● Nucleated cells in peripheral circulation ● Blood film: microcytic anaemia with sickled erythrocytes ●Hb 6-8g/dL ● High reticulocyte count● ● All investigations normal 
Imaging Nil Nil Nil Nil ● Endoscopy/ colonoscopy will reveal bleed ● CT angiography: reveals exact location of bleed N/A Nil Nil Nil N/A N/A 
Additional Investigations ● Bone marrow biopsy: erythroid hyperplasia and absence of iron● Jejunal biopsy may show small bowel disease ● Jejunal biopsy may show small bowel disease ● Coombs’ may be positive (if autoimmiune) ● Bone marrow trephine biopsy: hypocellular with increased fat spaces As above N/A ● Bone marrow biopsy: ineffective erythropoiesis leading to increased iron absorption, iron loading in marrow and haemosiderosis. ● Schilling test positive ● Bone marrow biopsy: hypercellular BM with megaloblastic changes● Jejunal biopsy may show small bowel disease ● Hb electrophoresis: raised HbF and absent/ low HbA ● Hb electrophoresis: 80-95%HbSS and absent HbA. N/A 
Full Article AnaemiasAnaemiasAnaemiasAnaemiasUpper GI bleedHypothyroidismAnaemiasAnaemiasThalassaemiaAnaemiasDepression




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