Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Fatigue
Fatigue - Key Features
1. In all patients complaining of fatigue, include depression in the differential diagnosis.
2. Ask about other constitutional symptoms as part of a systematic approach to rule out underlying medical causes in all patients complaining of fatigue.
3. Exclude adverse effects of medication as the cause in all patients complaining of fatigue.
4. Avoid early, routine investigations in patients with fatigue unless specific indications for such investigations are present.
5. Given patients with fatigue in whom other underlying disorders have been ruled out, assist them to place, in a therapeutic sense, the role of their life circumstances in their fatigue.
6. In patients whose fatigue has become chronic, manage supportively, while remaining vigilant for new diseases and illnesses.
Time Course of fatigue determines approach:
1-Recent Fatigue (less than 1 month)
- -Key: screen for depression. Ask about life stressors
- -Key: Laboratory evaluations in the absence of a positive history or physical examination are of little diagnostic utility in the evaluation of the fatigued patient
- -Key: screen for constitutional symptoms
- -Key: go through list of meds to see if there are any meds (hypnotics, antihypertensives, antidepressant meds, drug abuse, drug withdrawal)
2-Prolonged Fatigue (1 month to 6 months)
3-Chronic (over 6 months):
- -Key: support these patients, but don’t write off all new symptoms as due to the same fatigue syndrome!
- -Key: help patients figure out if lifestyle, life stressors are contributing
Clinical fatigue incorporates three components, present to variable degrees in individual patients: inability to initiate activity (perception of generalized weakness, in the absence of objective findings); reduced capacity to maintain activity (easy fatiguability); and difficulty with concentration, memory, and emotional stability (mental fatigue). Fatigue should be distinguished from somnolence, dyspnea, and muscle weakness, although these symptoms may also be associated with fatigue.
Hx: Onset, duration, course, impact on daily life, screen for psych dx, constitutional sx, organic dx, sleep pattern, meds (b-blockers, antihistamines, opioids), rec drugs
Px: General appearance, lymphadenopathy, thyroid exam, CVS/Resp (CHF, COPD), Neuro exam (muscle tone, bulk, strength, DTR, sensory, CN exam)
Labs:
- CBC with differential
- ESR
- Chemistry screen (including electrolytes, glucose, renal and liver function tests)
- Thyroid stimulating hormone (TSH)
- Creatine kinase (CK), if pain or muscle weakness present
Major Causes of Chronic Fatigue:
- V: CHF, COPD, Sleep apnea
- I: Endocarditis, TB, Mono, Hepatitis, Parasites, HIV, and CMV
- N: Occult malignancy, and severe anemia
- D: Hypnotics, Antihypertensives, Antidepressant meds, Drug abuse and drug withdrawal
- I: (dx of exclusion): Chronic fatigue syndrome (1-9%), Nonspecific Chronic Fatigue (Fatigue for which no medical or psychiatric explanation can be found is seen in 8.5 to 34 percent )
- A: Rheumatic Disease,
- T: Post-concussion syndrome
- E: DM, Hypothyroidism, Chronic Renal Failure, Liver failure, Hypercalcemia, Adrenal insufficiency
- Psychiatric: most common: present in 60- 80 % of patients with chronic fatigue. Depression (50%), Panic Disorder (14%), Anxiety Somatization (10%), Disturbed sleep
Chronic Fatigue Syndrome:
- If you are interested in checking out Canadian Guidelines on Chronic Fatigue Syndrome (AKA Myalgic Encephalomyelitis) go to http://www.mefmaction.net/documents/me_overview.pdf
- A diagnosis of exclusion—i.e.—you ruled out the above. However, dx is made mostly on history.
- Investigations: CBC, lytes, BUN Cr, TSH, ESR, and any other test for which there is a HIGH pre-test probability.
- Presentation:
- -VERY common. Often in young to middle aged, 2x more in women with fibromyalgia (70% of w CFS have fibromyalgia trigger points) and moderate to high socioeconomic status
- Hx-Relatively sudden onset of fatigue often associated with a typical infection such as an upper respiratory infection or true mononucleosis.
- - Patient is left with overwhelming fatigue and a number of additional symptoms, especially altered sleep and cognition.
- - Excessive physical activity characteristically exacerbates the symptoms.
- ****The pre-CFS medical history of the patient is not one of multiple somatic problems such as chronic backache or chronic headache. Affected patients are typically highly functioning individuals, some w psych hx, who are "struck down" with this disease****
- Definition of Chronic Fatigue:
- A-New onset fatigue that is persistent or relapsing, is not relieved by rest, is exacerbated by physical activity and has led to substantial reduction in activity
- And
- B-Four or more of the following symptoms during 6 or more consecutive months that do not predate the fatigue:
- -Impairment short-term memory
- -Muscle pain
- -Sore throat
- -New multi-joint pain without redness or swelling
- -New headaches
- -Tender axillary or cervical lymph nodes
- -unrefreshing sleep
- -Post-exertional malaise lasting over 24 hours.
Many patients with chronic fatigue syndrome are partially or totally disabled by its manifestations. Their outward, healthy appearance belies the internal sense of ill health. It is common for relatives and colleagues to accuse them of malingering. A vicious cycle of frustration, anger, and depression commonly ensues.
Treatment:
1-Support and Trust: The patient has to believe that YOU believe that they have a real illness or you can’t help them. Most of them feel guilty as it is.
2-Graded exercise program to prevent deconditioning and further fatigue/weakness
3-CBT