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Fatigue and Neck Swelling History taking + Data interpretation Shehza and Ebrahim 4 Year Medical StudentsIn Partnership with Enrolled activity under the International Federation of Medical Students’ Association (IFMSA) Teaching Medical Skills programme. In Partnership with Comprehensive, accessible OSCE resources, notes, videos and OSCE stations for practice. Use CODEBLUE24 at checkout on GeekyMedics.com for 15% off their paid resources (not an affiliate code) Disclaimer • Code Blue OSCE Crew is a platform created by Manchester medical students, independently of the University of Manchester and Manchester Students’ Union • This teaching should not replace any formal teaching provided by the university - Any changes to CCAs would be communicated by your university, follow their guidance • Content is generated by students with input from senior doctors Session Structure Neutropenic Group sepsis + fatigue practice! Leukaemia and Breakout rooms for 1 CCA station Lymphoma hour of OSCE practice tips Learning Objectives: ● Recall common conditions associated with fatigue and neck lumps ● Recall and apply the structure of a general history to a patient presenting with a neck lump ● Recall red flag symptoms of a neck lump history ● Recall and apply the steps of data interpretation to analysing FBC, especially for the following conditions - neutropenic sepsis - haematological malignancies such as leukaemia (ALL, CLL, CML, AML) ● Recall and apply the steps of data interpretation to analysing blood films and lymph node biopsies e.g,: - Reed-Sternberng cells in Hodgkin’s lymphoma (Y3 CCAs June 2023)Leukaemias What types of leukaemia do you know? ● Acute lymphoblastic leukaemia ● Acute myeloid leukaemia ● Chronic lymphocytic leukaemia ● Chronic myeloblastic leukaemia Acute leukaemias - failure of lymphoid/myeloid progenitor cells to differentiate, causing uncontrolled proliferation of these immature blast cells Chronic leukaemias - the uncontrolled proliferation of cells at a later stage of differentiationALL (seen in children!) ● The most common paediatric leukaemia, usually in under 5s ● Lymphocyte precursor cells are affected → acute proliferation of B-lymphocytes (usually) ● Lymphocytosis crowds out other cell types in bone marrow → pancytopaeniaCLL ● Affects adults over 60 years ● Slow proliferation of 1 type of differentiated lymphocyte (usually B-lymphocytes) ○ Causes lymphocytopenia ● Often asymptomatic ○ But can present with infections, anaemia, bleeding, weight lossAML ● Can present at any age, usually 40+ ● Can be caused by myelodysplastic syndrome and myeloproliferative disorders ● Uncontrolled growth of myeloid cells in bone marrow ○ Causes proliferation of immature, non-functional WBCs (“blasts”) ○ Disrupts normal haematopoiesis → pancytopeniaCML ● Affects adults over 60 years ● Uncontrolled growth of differentiated myeloid cells in bone marrow ○ These cells can crowd out the bone marrow and cause reduced production of platelets and RBCs ● 3 phases of disease ○ Chronic phase - asymptomatic/mild symptoms ○ Accelerated phase - disease is progessing, blast crisis is imminenet ○ Blast crisis - behaves like acute leukaemia with rapid progression and short survival Characteristic Acute Lymphoblastic Leukemia (ALL) Acute Myeloid Leukemia (AML) Chronic Lymphocytic Leukemia (CLL) Chronic Myeloid Leukemia (CML) More common in children, but can occur Affects mainly adults, with a slight male Incidence Affects both adults and children Primarily diagnosed in older adults in adults predominance - Fatigue - Fatigue - Fatigue - Fatigue, weight loss, abdominal discomfort Symptoms - Frequent infections - Frequent infections - Enlarged lymph nodes - Enlarged spleen and liver, night sweats - Pale skin - Pale skin - Enlarged spleen and liver - Easy bruising, bone pain, abdominal fullness - Blood tests - Blood tests - Blood tests, bone marrow biopsy - Blood tests, bone marrow biopsy Diagnosis - Bone marrow biopsy - Bone marrow biopsy - Flow cytometry - Chromosomal analysis (Philadelphia chromosome) - Chemotherapy - Chemotherapy - Watch and wait for slow-progressing cases - Targeted therapy (tyrosine kinase inhibitors) - Immunotherapy (e.g., monoclonal - Chemotherapy, targeted therapy, stem cell Treatment - Stem cell transplant in some cases - Stem cell transplant in some cases antibodies) transplant - Targeted therapy (for specific genetic - Targeted therapy (for specific genetic - Monitoring and medication (e.g., tyrosine kinase - Chemotherapy mutations) mutations) inhibitors) Varies depending on age, overall Improved with targeted therapy; can be managed for Prognosis Generally good, especially in children Slow progression; survival rates vary health, and genetic factors many yearsNeck lump history taking What would you include when taking history? ● SOCRATES ● Haematologics systems review ● PMHx ○ Ask specifically about past lymphoma Never forget ● Drug history + allergies ICE ! ● Family history ● Social history ○ include smoking, alcohol, recreational drugs ● Travel historyWhat are the red flags for a neck lump? ● Weight loss What would you do next if a patient ● Night Sweats came to GP with this? ● Dysphagia ● 2 week wait ● Odynophagia ● Hoarseness > 3 weeks ● Unexplained bruising ● Recurrent infectionsData interpretation summary ALL CLL AML CML Hodgkin’s lymphoma Non-Hodgkin’s lymphome FBC ● Lymphocytosis ● Lymphocytopenia ● Anaemia ● Raised ● Normal in early Same as HL ● Pancytopenia of ● Thrombocytopenia granulocytes/ disease ● Abnormal WCC other cells ● Abnormal WCC WCC ● Abnormal in later ● Anaemia ● Anaemia disease - suggest ● Thrombocytopenia ● Thrombocytpenia tumour cells have invaded blood and/or bone marrow Blood ● Many immature ● Smear/Smudge ● Myeloblasts - ● All stages of ● Reed-Sternberg cells ● Atypical film lymphoblast cells (ruptured immature cells granulocyte lymphocytes cells WBCs bc they are with large nuclei maturation seen ● Cytopenias aged/fragile) ● Auer rods ● Rouleaux formation of RBCsNeutropenic Sepsis (Febrile Neutropenia) ● Definition: One of few oncological emergencies that happen in cancer patients following chemotherapy use. ● Signs & Symptoms -> Non-specific symptoms of infection (chills, sore throat, cough, etc.) ● Organisms -> Most commonly gram positives (staph aureus, staph epidermidis, strep pneumo) ● Investigations -> Basic Observations (↓BP, ↑RR, ↑HR), FBC, lactate, CRP?, U&Es, Blood cultures ● Diagnosis -> Neutropenia (Neutrophils less than 0.5 x10 ) + One of the following: ○ Fever > 38 ○ Symptoms of infection ● Management -> Immediate hospital admission & Antibiotic therapy (& Remaining of Sepsis 6) ● Antibiotic of choice -> Piperacillin/Tazobactam (A broad spectrum agent) ○ Penicillin allergy -> Meropenem ○ Prophylaxis in high-risk patient -> Fluoroquinolones (ciprofloxacin) ○ Possible future agent? -> G-CSFLymphomas ● Definition -> Malignant proliferation of lymphocytes ● Risk Factors ○ Age -> Much more common in older people ○ Infections (EBV, HIV, H. pylori, etc) ○ Immunodeficiency (E.g. Immunosuppressant use) ○ Autoimmune conditions (Pernicious anaemia, Coeliac, etc) ● Signs & Symptoms ○ B symptoms (fatigue, fever, night sweats, weight loss)metrical ○ Hepatosplenomegaly ○ Extra-nodal symptoms -> GI symptoms (dysphagia dyspepsia), Bone pain, etcLymphomas Types 1- Hodgkin’s Lymphoma 2- Non-Hodgkin’s lymphoma Investigation FBC & Blood film -> AOCD? Ruling out leukemias - LDH - PET/CT for staging - Excisional Biopsy Sample (not needle biopsy) Staging - Ann-Arbor System -> Historical classification depending on number of nodes - Lugano System -> Recent system that uses PET scan to locate lymphadenopathyLymphomas: Hodgkin’s & Non-Hodgkin’s 1- Hodgkin’s Lymphoma -A type of lymphoma that is characterized by presence of Reed-Steerneberg cells -These cells are large having with bilobular nucleus “owl’s-eye appearance” -Alcohol-induced lymph node pain is an uncommon but characteristic symptom -Managed by ABVD Chemotherapy regimen -B-symptoms occur earlier in Hodgkin’s lymphoma -Has bi-modal age distribution (common young adulthood and ages over 55) 2- Non-Hodgkin’s lymphoma -An umbrella term for all the other lymphomas (MALT lymphoma, EATL, Mantle zone lymphoma, etc) - Much more common than Hodgkin’s lymphoma -Most common subtype is diffuse large B-cell lymphoma -Extra-nodal involvement is common (GI symptoms, etc) - Managed by R-CHOP Chemotherapy regimenLymphomas: Hodgkin’s & Non-Hodgkin’s - A detailed history & physical examination should precede -The Investigation of choice is always “Excisional lymph node biopsy” -Other investigations -> FBC, LDH, HIV test, etc -Biopsy finding: 1- Hodgkin’s Lymphoma: - Characteristic owl’s-eye appearance RS cells - CD15 & CD30 positive 2- Non-Hodgkin’s lymphoma - Many subtypes - Lymphocytosis with abnormally-shaped cells - Findings depends on the subtype - CD19 & CD20 positiveMultiple Myeloma Definition: Cancer of plasma cells producing excessive antibodies (immunoglobulins) that are ineffective. Epidemiology: Men > Women Mean Age of Presentation -> 70 Risk Factors -> Genetics, radiation exposure Features (CRABBI) Calcium -> Lytic bone lesions causing inflammation & calcium release Renal -> Renal failure due to protein chain deposition Anaemia -> AOCD due to decreased erythropoiesis Bleeding -> Due to thrombocytopenia Bone Pain -> Causes by plasma cells causing lytic lesions Infection -> The new immunoglobulins are ineffective & thereby increases the risk of infectionMultiple Myeloma Investigation - FBC showing anaemia (can be normo- or microcytic), thrombocytopenia - Blood film showing rouleaux formation - U&Es showing renal failure - Bone Profile -> Calcium & ALP levels - Urine sample showing Bence-Jones proteins - Bone x-ray -> raindrop appearance - Whole-Body MRI to detect bone lesions - Best Initial Test -> Serum electrophoresis showing M-proteins - Definitive diagnosis -> Bone Marrow Biopsy Management - Chemotherapy ± Bone marrow transplantFatigue: History Taking ● Introduction ● Open Question “What brought you here?” ● Symptom Exploration “First time?, Duration, Onset, Timeline, Alleviating or Aggravating Factors, etc.” ● Mini Review of Systems -> Have you noticed any other symptoms? Ask specifically about fever, night sweats, lumps & bumps, polyuria, mood, etc ● ICEF followed by Empathy Statement ● Ask about periods in females ● PMH (ask about lymphomas/leukemia) & PSH (could be bleeding after surgery?) ● DH & allergies ● FH, SH (ask about sleep, diet, travel, smoking etc) ● SummaryFatigue: Differentials ● Lymphoma -> B symptoms (night sweats, lumps/bumps, fever, appetite loss) ● IDA -> Cold peripheries, shortness of breath -> Can be caused by bleeding somewhere (Bowel Ca) ● Thyroid Disease -> Constipation/Diarrhea, Cold/Heat intolerance, Weight loss/gain, etc ● Viral Infection -> Muscle aches, runny nose, sore throat, mild cough, mild fever ● DM -> Polyuria, polydipsia, fatigue, thrush ● Addison’s Disease -> Weight loss, salt craving, dizziness, salt craving ● Psychiatric -> Low mood, anhedonia, stress, reduced concentration, sleep problems, etc ● Menorrhagia -> Heavy periods (mostly idiopathic)Respond on the feedback forms to get the slides :) linktr.ee/codeblueteaching cbosceteaching@gmail.com IG: @codeblueteaching facebook.com/cbosceteaching Now for OSCE practice!