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Fatigue, bad night of sleep or something more serious? An incredibly common presentation to all healthcare settings, have a go at these questions and learn about some causes of fatigue!

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Fatigue

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Question 1

Stem 1, question 1 of 5

Sam, a 28 year old,  presents to GP with a 6 month history of fatigue

Fibromyalgia is a cause fatigue, what is fibromyalgia?
A
A sudden or gradual onset of persistent disabling fatigue, post-exertional malaise, unrefreshing sleep with cognitive and autonomic dysfunction lasting at least 6 months
B
A cancer of the lymphocytes
C
A chronic pain syndrome diagnosed by the presence of widespread body pain for at least 3 months in addition to tenderness of at least 11 out of 18 designated points.
D
An infection that results in chronic cough, fatigue, night sweats and weight loss
E
A condition that describes a vague myriad of symptoms including painless lympadenopathy, nocturnal diaphoresis and unintentional weight loss.
Question 1 Explanation: 
Fibromyalgia is a chronic pain syndrome with widespread body pain and point tenders at a minimum of 11 of 19 points across the body. As this is a clinical diagnosis often it is dismissed and stigmatised however there is a clear underlying pathology. BMJ best practice has a great page on this condition: https://bestpractice.bmj.com/topics/en-gb/187
Question 2

Stem 1, question 2 of 5

Hypothyroidism is also a cause of fatigue, which of the following is not an examination finding in hypothyroidism?
A
Peri-orbital oedema
B
Macroglossia
C
Diastolic hypertension
D
Blue sclera
E
Bradycardia
Question 2 Explanation: 
Blue sclera is a sign of anaemia not hypothyroidism. All others are examination findings that can be seen in hypothyroidism, remember not every patient will have all possible examination findings! Hypothyroidism and depression can be hard to differentiate as both may present with slowed movement and speech as well as fatigue. You history should help to guide you but you may need to do some investigations too.
Question 3

Stem 1, question 3 of 5

If there was recent travel history and no previous BCG vaccination which cause of fatigue is more likely?
A
Pneumonia
B
Measles
C
Tuberculosis
D
Infectious mononucleosis
E
HIV
Question 3 Explanation: 
The BCG vaccination protects against Tuberculosis infection. Some areas of the world have higher rates of tuberculosis and so if a person has recently travelled to these areas, it is worth having TB as a differential! Here's a list by the UK government of rates of TB per country which you may find helpful! https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people
Question 4

Stem 1, question 4 of 5

Which do the following medications do not cause fatigue as a side effect?
A
Propranolol
B
Diazepam
C
Prednisolone
D
Beclomethasone
E
Tetrabenazine
Question 4 Explanation: 
Beta-blockers (propranolol), benzodiazepines (diazepam) and corticosteroids (prednisolone and beclomethasone) are well known for causing fatigue. Many drugs can result in fatigue and it is one of the most common side effects. Tetrabenazine is a dopamine depleting drug used in Huntington's disease. As always the BNF is super helpful when considering drug side effects!
Question 5

Stem 1, question 5 of 5

Sam's GP requests some blood tests and receives the following lab report: Macrocytic anaemia seen.

What is the most likely cause of Sam's macrocytic anaemia?
A
Iron deficiency
B
Thalassemia
C
Sickle cell disease
D
B12/folate deficiency
E
Chronic kidney disease
Question 5 Explanation: 
B12 and folate are needed for DNA synthesis and to aid in the explosion of DNA from the erythrocyte, if there is a deficiency, the erythrocyte is unable to shrink down in size and thus there is a macrocytic anaemia. Iron deficicency, thalassemia and sickle cell all result in microcytic anaemia and chronic kidney disease normally results in a normocytic anaemia.
Question 6

Stem 2, question 1 of 5

Matthew, a 56 year old man, presents to his GP feeling tired all the time and struggling to stay awake during the day.

What is obstructive sleep apnoea?
A
Characterised by repetitive absent or diminished respiratory efforts that occur intermittently or in a cyclical pattern predominantly during sleep.
B
Obstruction of the nasopharynx only during sleep
C
Episodes of apnoea due to externally applied pressure
D
Characterised by episodes of complete or partial upper airway obstruction during sleep
E
Characterised by episodes of complete or partial lower airway obstruction during sleep
Question 6 Explanation: 
Obstructive sleep apnoea is like the name suggests: an obstruction occurring during sleep that stops breathing! The obstruction is in the upper airway and differs to central sleep apnoea which is repetitive absent or diminished respiratory efforts occurring intermittently or cyclically during sleep.
Question 7

Stem 2, question 2 of 5

Which of the following is not part of the management of obstructive sleep apnoea?
A
Support to help loose weight if individual is overweight
B
Continuous positive airway pressure at night
C
Positioning at night to help reduce risk of obstruction
D
Surgical excision of discrete anatomical lesions
E
Treatment with sildenafil
Question 7 Explanation: 
Obstructive sleep apnoea can be treated in a number of ways. Conservatively by supported weight loss and position changes. Medically by continuous positive airway pressure and modafinil aka the study drug as this can help reduce the tiredness an individual feels and finally surgically by the removal of any anatomical blockages. Sildenafil is not used in the management of sleep apnoea
Question 8

Stem 2, question 3 of 5

9 months later after successful treatment for his obstructive sleep apnoea, Matthew returns to his GP with fatigue, polyuria, weight loss and polydipsia.

What is the most likely diagnosis?
A
Hyperthryoidism
B
Diabetes mellitus
C
Anaemia of chronic disease
D
Adrenal insufficiency
E
Malignancy
Question 8 Explanation: 
Matthew is describing key hallmarks of diabetes mellitus, remember that type 1 diabetes can occur at any age, it is just more common for it to occur in children. Please don't automatically assume that a diagnosis of diabetes above childhood is always type 2.
Question 9

Stem 2, question 4 of 5

Matthew's wife, Jennifer, presents to the GP with fatigue, anorexia, nausea, vomiting and hyperpigmentation of her gums and she is craving salty foods

What is the most likely diagnosis?
A
Hypothyroidism
B
Hyperthyroidism
C
Depression
D
Chronic fatigue syndrome
E
Adrenal insufficiency
Question 9 Explanation: 
Adrenal insufficiency aka Addison's disease presents acutely or insidiously with substantial fatigue, mucocutanous hyperpigmentation along with anorexia, nausea and vomiting. Individuals may also crave salty foods too!
Question 10

Stem 2, question 5 of 5

What is the treatment of Addison's disease?
A
Glucocorticoid only
B
Glucocorticoid and mineralocorticoid
C
Mineralocorticoid only
D
Androgen replacement
E
Thyroid hormone replacement
Question 10 Explanation: 
Oral glucocorticoid and mineralocorticoid replacement therapy is given in physiological doses for life with additional dosing if someone is in stress aka another illness. BMJ best practice has really great guidance on treating Addison's disease: https://bestpractice.bmj.com/topics/en-gb/56/treatment-algorithm
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