A 45 year old man has felt vaguely fatigued for around 1 month, but certainly in the last week has noticed a significant feeling of lethargy. In addition, he has also reported symptoms which you interpret as myalgia.
How would you examine this patient and what additional examination findings would you look for?
Fatigue is possibly the most non-specific of all medical complaints, and warrants examination of all body symptoms. Indeed, tiredness can also be a sign of depression, so enquiring into the patients mood and a psychosocial history is also warranted:
This is by no means extensive:
Cardiovascular: Ischaemic Heart Disease, Heart Failure, valvular disease.
Respiratory: atypical pneumonia, viral URTI, COPD, lung cancer.
Gastroenterology - hepatitis,
Haematological - anaemia and any leukaemia's
Oncology - essentially all malignant processes
Endocrinology - addisions, cushings, thyroid disease, hyponatraemia, hypercalcaemia.
Rheumatological conditions, lots.
Infections - post glandular, post lots of viruses, TB.
Neurological - MS, Myaesthenia Gravis. Vitamin Deficiencies.
Renal - renal failure.
Other things - Drugs, Beta-blockers, are they actually sleeping?
baseline tests might include.
FBE - anaemia, any sign of infection, blood malignancy, platelet function.
UECs - renal function, sodium
C/M/P - high calcium often causes extremely lethargy in multiple myeloma patients.
LFTs/coags - hepatitis
The liver function tests demonstrate the following result show the following:
Bilirubin 21 µmol/l
ALT 103 IU/L [7-55]
AST 115 IU/L [8-48]
ALP 45 U/L [45-115]
GGT 43 IU/L [9-48]
Which of the following conditions are potential causes of the liver function test abnormalities?
B. Prescribed medications
C. Autoimmune hepatitis
D. Pancreatic carcinoma
E. Viral infection
This is a hepatocellular picture, rather than obstructive or mixed as the AST and ALT are the predominantly elevated liver enzymes. There are numerous causes, including autoimmune hepatitis, alcohol, fatty liver disease, viral infections and medications especially antibiotics.
Causes of an obstructive picture include pancreatic carcinoma, biliary strictures, bile duct calculi and cholangiocarcinoma.