CASE 93: TIREDNESS
History
A 79-year-old man is brought to his general practitioner by his daughter who says that he
is getting very tired and has lost interest in life. She says that a general malaise has been
present for 5–6 weeks. She thinks that he might have lost a few kilograms in weight over
this time, but he does not weigh himself regularly. He says that he has felt limited on exer-
tion by tiredness for a year or so, and on a few occasions when he tried to do more he had
a feeling of tightness across his chest. There is no other medical history of note. He smokes
20 cigarettes a day and drinks a pint or two of Guinness each Saturday and Sunday. He is
not on any medication, just taking occasional paracetamol. On systems review, he says
that he has lost his appetite over the last month. His sleep has been disturbed by occa-
sional nocturia, and on two or three occasions in the last few weeks he has been disturbed
by sweating at night.
There is no relevant family history. He is a retired shopkeeper who normally keeps rea-
sonably fit walking his dog.
Examination
His pulse is 70/min, blood pressure 110/66 mmHg. There is no clubbing, but tar staining is
present on the fingers and nails of the right hand. The jugular venous pressure is not
raised. The apex beat is displaced 2 cm from the midclavicular line. On auscultation of the
heart there is a grade 3/6 ejection systolic murmur radiating to the carotids and a soft
early diastolic murmur audible at the lower left sternal edge. There are no abnormalities
to find in the abdomen or nervous system. The urine looked clear but routine stick test-
ing showed a trace of blood and on urine microscopy there were some red cells. A chest
X-ray was reported as showing a slightly large heart.
NormalHaemoglobin 10.7 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 88 fL 80–99 fL
White cell count 12.2% 109 /L 3.9–10.6% 109 /L
Neutrophils 10.5% 109 /L 1.8–7.7% 109 /L
Lymphocytes 1.5% 109 /L 0.6–4.8% 109 /L
Platelets 287 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate (ESR) 68 mm in 1 h !20 mm in 1 hThe electrocardiogram (ECG) is shown in Fig. 93.1.