What should be an initial response to a case?
Ideas
Concerns
Expectations.
What is the traditional structural history taking model composed of?
PC
HPC
PMH
Drugs
Social history
Family history
System reviews
What are the benefits and disadvantages of the traditional model?
Benefits=comprehensive, logical, easy to communicate.
Disads= time heavy, promotes closed questions, focuses on Dr agenda than patient agenda.
Describe the Calgary-Cambridge framework.
Helps to develop more rapport with patient than traditional route.
What could a patient mean when they are “tired all the time”?
An umbrella term encompassing patients presenting with increasing
lethargy / reduced energy levels / increased somnolence / fatigue etc
A vast differential – many physical pathological processes result in
reduced energy levels
But tiredness does not necessarily mean there is physical pathology.
Many mental health issues can manifest with lethargy eg depression.
And many normal aspects of life can cause tiredness eg new baby,
stressful job etc.
Doesn’t help to narrow done root cause (non-specific symptom).
What are some targeted questions you would ask her?
Menstrual loss.
Pregnancy
Dietary history (vegan)
Travel history
Features of malignancy- weight loss, night sweats, lumps and bumps.
What are examples of bedside tests?
- Capillary Blood Glucose Monitoring
- Urinalysis
- Blood pressure
- Oxygen Saturations
- Pregnancy test!
What are examples of some lab tests that could be carried out?
- Full Blood Count
- Renal Function (Urea and Electrolytes)
- Thyroid Function Test
- Iron Profile
- Vitamin B12 / Folate
You might also consider sending; - Liver Function Testing
- Autoantibody screen
- Viral PCR testing e.g. Epstein Barr Virus
- ESR / CRP.
What more specific tests might be completed (for anaemia to try find root cause)?
- Reticulocytes
- Iron Profile
- Blood film
- B12/Folate
- Direct Coombes test
- Haptoglobin
- Bilirubin
- Haemoglobin Electrophoresis and High Performance Liquid
Chromatography.
What does NEWS chart stand for?
National early warning signs chart.
What should be a question to consider is there is an extreme downfall of haemoglobin etc?
Could the patient be bleeding?
What systems can be altered from anaemia?
Respiratory system – increased respiratory rate, increased tidal volume
Therefore feels short of breath
Cardiovascular system – increased heart rate, increased stroke volume
Therefore can get palpitations from tachycardia
Neurological system – reduced oxygen perfusion of the brain
Therefore feel light headed, collapse.
What should you do after detecting an iron deficiency?
Find the cause- Decreased iron absorption-
Use Insufficient dietary intake
Gut pathology eg coeliac
disease, Crohns disease
Increased iron use- Increased erythropoiesis
due to increased blood
loss or red cell destruction
Occult GI bleeding
Gynaecological bleeding.
Why might this patient have decreased iron absorption?
Vegan Diet – Important as Iron is
most easily absorbed as haem
iron (animal protein)
Low BMI – Could the patient
have an eating disorder?
No overt gut pathology however
coeliac disease can be otherwise
asymptomatic.
Why might this patient have increased iron absorption?
Chronic Blood Loss
* Menorrhagia
* GI blood loss
(Benign cause or Malignant cause)
If the patient has menorrhagia
then need to keep thinking…
* Anatomical issue eg fibroids,
endometriosis
* Clotting issue eg VWD,
thrombocytopenia
* Hormonal issue
* Other cause.
What are some treatments used in order to receive iron?
Can be given as a daily oral
preparation (Cheap, usually
effective but GI side effects
mean it can be poorly
tolerated)
Or as an intravenous infusion
(Expensive, resource heavy but
very effective if patients need a
rapid increase in Hb or can’t
take oral iron).
What are some treatment options for a Vit B12 deficiency?
1) Reduced Dietary B12 -
only present from animal
sources (eg dairy)=Suitable for oral replacement with
cyanocobalamin
Could supplement diet or include
fortified foods
2) Failure of absorption ;
Pernicious anaemia,
Terminal ileum disease-
Oral replacement will not work
Therefore parenteral administration
required with IM Hydroxycobalamin.
Why might a patient have non-adherence?
Disease factors (e.g. few, or mild symptoms);
healthcare factors (poor availability of services);
patient factors (negative attitudes to the treatment, beliefs that the illness is not severe);
psychosocial factors (poor mood, poor support)
treatment factors (complex regimens, unpleasant side-effects).
Involving the patient in decision making, agreeing a treatment plan may
be factors that can improve medication adherence.
Why is health education important in this circumstance?
Health Education is a key aspect of the role of the doctor – how we can
prevent this from happening again.
In this case it is likely that poor dietary understanding has resulted in
nutritional deficiency of iron and vitamin B12.
In this case a dietician will have more time and expertise to assess the
patients diet.
They will be better placed to make specific individualised
recommendations regarding iron and B12 in the vegan diet.
(MDT very important).
