26: 55-year-old man with fatigue

Question 1

Fatigue vs. sleepiness

Answer 1

fatigue - A feeling of exhaustion or tiredness that is pervasive, not relieved by rest, and often worsened by exertion.

sleepiness - A feeling of tiredness that gives a patient the tendency to fall asleep, and is often relieved by either rest or exertion.

Question 2

Common causes of fatigue

Answer 2

Psychological causes
Depression, anxiety, adjustment reaction, substance abuse.

Secondary physical causes
Side effects of medications, diabetes, hypo- or hyperthyroidism, anemia, acute infection, cardiovascular disease (e.g. congestive heart failure), lung disease (e.g. chronic obstructive pulmonary disease), chronic inflammatory conditions (e.g. rheumatoid arthritis), malignancy, pregnancy and electrolyte imbalances (e.g. hypercalcemia).

Physiologic causes
Acute decrease in sleep (e.g., due to parenting a sick child), alternating shift work, and inadequate or poor quality sleep. The latter may be further broken down into primary sleep disorders (e.g., restless leg syndrome and obstructive sleep apnea), lifestyle issues (increased physical exertion), and medical causes (e.g., sleep interrupted by nocturia or pain).

primary fatigue :
Chronic fatigue syndrome and fibromyalgia.

Question 3

Ankle Clonus

Answer 3

A series of abnormal alternating contractions and relaxations of the foot induced by sudden dorsiflexion of the foot. Its presence is suggestive of upper motor neuron pathology.

Question 4

Depression Screening: PHQ-2

Answer 4

The PHQ-2 involves asking patients, “Over the last two weeks, how often have you been bothered by any of the following problems?”
(1) “Little interest or pleasure in doing things.” (2) “Feeling down, depressed, or hopeless.” For each question, the patient can answer:
“not at all” (0 points)
“several days” (1 point)
“more than half the days” (2 points), “nearly every day” (3 points).

The score from the two symptoms questions are then added together into a final score.

Question 5

Breast Cancer Screening Recommendations

Answer 5

The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every two years for women aged 50 to 74 years (Grade B recommendation).

They recently updated their recommendation regarding mammography for women aged 40-49. Whereas they previously recommended routine mammography, they now recommend that patients and doctors should make individual decisions based on the patient’s risks and health preferences (Grade C recommendation).

Teaching self-breast examination (SBE) is not recommended (Grade D recommendation) as it has shown only to increase rates of biopsy without improving cancer detection or treatment.

USPSTF also recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing (Grade B recommendation).

Question 6

Colorectal Cancer Screening Recommendations

Answer 6

The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years (Grade A recommendation).

They give a C (equivocal) recommendation for screening adults between 76 and 85 years

They recommend a variety of possible screening strategies, including: fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), fecal DNA testing (FIT-DNA), colonoscopy, flexible sigmoidoscopy, and CT colography

Only flexible sigmoidoscopy and FOBT testing have randomized trial data proving their efficacy.

Question 7

Cervical Cancer Screening Recommendations

Answer 7

Screening for cervical cancer with Pap smear in women ages 21 to 65 years who have a cervix (regardless of sexual history) is recommended by the USPSTF (Grade A recommendation) every three years. (Women ages 30 to 65 may increase the interval to every five years if human papillomavirus [HPV] testing is also obtained.)

Question 8

Lung Cancer Screening Recommendations

Answer 8

The USPSTF gives a B statement to screening for lung cancer with annual low-dose computed tomography (LDCT) for people aged 55-80 years who have a 30 pack-year smoking history and who currently smoke (or have quit within the past 15 years).

This recommendation is based on a single randomized trial that demonstrated a 20% reduction in lung cancer deaths among heavy smokers as well as a slight reduction in all-cause mortality with annual LDCT screening


Question 9

Prostate Cancer Screening Recommendations

Answer 9

Due to findings that “many men are harmed as a result of prostate cancer screening and few, if any, benefit,” prostate specific antigen (PSA) testing for prostate cancer is given a D rating (it is recommended against).

Prostate cancer is the second most common cancer killer among men, so there is considerable desire to develop an effective screening strategy.

Question 10

Pancreatic Cancer Screening Recommendations

Answer 10

Like lung cancer, pancreatic cancer has a poor prognosis once diagnosed, so there is interest in developing screening tests for primary prevention. However, currently no such test is available, and the USPSTF gives pancreatic cancer screening a Grade D.

Question 11

Testicular Cancer Screening Recommendations

Answer 11

Testicular cancer screening gets a Grade D rating from the USPSTF. In this case, the low incidence of disease and the favorable outcomes of treatment at any stage make screening unlikely to improve outcomes beyond what they are now.

Question 12

Skin Cancer Screening Recommendations

Answer 12

The USPSTF currently gives skin cancer screening by total-body skin exam (by either primary care clinician or patient) an I rating due to a lack of strong evidence that such screening improves outcomes.

Due to the benign and low-risk nature of the test itself, many clinicians provide this service despite the USPSTF’s I statement.

Question 13

Barriers to cancer screening include:

Answer 13

lack of awareness
denial of vulnerability
lack of insurance (64% of eligible persons without insurance have not been screened) not having received a screening recommendation
fear of pain with a procedure
fear of finding bad results

Question 14

Causes of Iron Deficiency Anemia

Answer 14

In adult men and post-menopausal women, gastrointestinal (GI) blood loss is the most likely cause of iron deficiency. When an adult male presents with bright red blood per rectum and iron deficiency anemia, it suggests lower GI tract bleeding. As such, colorectal carcinoma, colon polyps, or bleeding diverticuli are likely diagnoses. Peptic ulcer disease and gastritis are common causes of chronic GI blood loss, but these typically present with guaiac positive stool that is brown (if bleeding is chronic) or black (if bleeding is brisk) – and hence are less likely diagnoses in the case of bright red blood per rectum.

Chronic hematuria can cause iron deficiency but is relatively rare. It can be caused by nephritic syndromes, renal cancers, and bladder cancers.

Dietary iron is absorbed in the duodenum and jejunum. Diseases affecting absorption in the small bowel include celiac sprue.

Dietary iron is found in meat, dairy products and some vegetables. Some vegans become iron deficient due to inadequate intake. This may be exacerbated by menstrual blood loss among young women. It would be important to clarify diet to see if the patient is not getting enough iron; however, this is rare cause of iron deficiency in the US.

Question 15

CRC RF

Answer 15

• -Age - 90% of colorectal cancer occurs after the age of 50.
• -Hereditary conditions (such as familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer)
• -Personal history of colorectal cancer or adenomas
• -First-degree relative with colorectal cancer (increases risk of colorectal cancer 1.7 fold)
• -First-degree relative with adenomas diagnosed before age 60 years
• -Personal history of ovarian, endometrial, or breast cancer
• -Personal history of long-standing chronic ulcerative colitis or Crohn’s disease
• -Personal history of diabetes.

Question 16

CRC DIet

Answer 16

> > Obesity has been shown to increase the risk of colorectal cancer mortality.
Fat intake increases the risk of developing adenomatous polyps, but not necessarily colorectal cancer.
There are mixed results from studies regarding whether the consumption of red meat increases the incidence of colon cancer.
A systematic review failed to show any benefit from increasing dietary fiber consumption on the incidence of colorectal cancer.

Question 17

Colon Cancer Screening Recommendations

Answer 17

Colonoscopy
Every 10 years
This is the most commonly used method, but many patients don’t adhere to this recommendation if it is the only option

Flexible sigmoidoscopy
Every 5 years
Multiple randomized trials support this test, though it has become less available in the US.

Fecal occult blood testing (FOBT)
Every year
Large randomized trial supports the use of this test. Three samples need to be collected by the patient at home.

Fecal immunochemical testing (FIT)
Every year
While there are no randomized trials, this test has better accuracy than FOBT and may be done with a single sample collected at home.

Fecal DNA testing (FIT-DNA)
Every 1 to 3 years
More sensitive than FIT or FOBT, but lower specificity, leading to more false positive tests and therefore unnecessary colonoscopies

CT colonography
Every 5 No randomized trial. Low procedural risk (compared to colonoscopy), but years significant radiation exposure and risk of incidental findings leading to
unnecessary work-ups.

Flexible sigmoidoscopy combined with FIT testing
Every 10 years
Evidence from a subset analysis of one randomized trial.

Question 18

Clinical Staging of Colorectal Cancer

Answer 18

An essential element in the clinical staging of colorectal cancer is the depth of the invasion of the bowel wall. For colon cancers, this cannot be determined until the cancer is surgically removed (pathologic staging). In the case of rectal cancers, endorectal ultrasoundprovides oncologists with fairly accurate estimates of the depth of invasion and may guide therapy.

The most common sites of metastasis for colorectal cancers are the pelvic lymph nodes, liver and lung. As such, a CT scan of the pelvis and abdomen,as well as a chest x-ray are appropriate for initial clinical staging.

CEA (carcinoembryonic antigen) is elevated in many colorectal cancers as well as a variety of benign conditions. Elevation of CEA above 5 ng/ml is associated with a worse prognosis at each stage and is therefore helpful in determining prognosis.

Question 19

Some physicians recommend the SPIKES strategy for delivering bad news. Its six steps are below:

Answer 19

Setting up the interview: Arrange a private room where you can sit face to face with the patient. Encourage the patient to bring family members for support. Make eye contact during the interview.

Perception: Use the rule, “before you tell, ask.” Find out what is the patient’s understanding of the situation before launching into an explanation. This allows you to dispel misinformation and identify denial.

Invitation: Because a minority of patients do not want to learn about bad news, ask how the patient would like you to explain the information about the diagnosis.

Give Knowledge and information to the patient: Expressing your own emotions about the bad news can lessen the shock of the news (e.g. “It makes me very sad to have to tell you that…”). Make sure to use non- technical words and avoid being overly blunt.

Address the patient’s Emotions with empathic responses: First, identify the emotion the patient is expressing and identify the reason for it (usually this is related to the bad news). Then let the patient know that you understand their emotion (e.g. “I can tell you weren’t expecting to hear this.” “I imagine this isn’t what you wanted to hear.”).

Strategy and Summary: Laying out a plan for what will happen next, including how the patient can contact you and when you will see them again, can relieve anxiety and uncertainty for the patient. Summarizing the information and checking for understanding can prevent misunderstandings and avoid either an overly optimistic or pessimistic response by the patient.

Question 20

Iron Deficiency Treatment

Answer 20

ferrous sulfate 325 mg three times daily

docusate sodium 100 mg twice daily as needed for constipation

Question 21

Evaluation of Fatigue

Answer 21

A CBC and ESR are commonly included in the initial evaluation.

Diabetes is a common cause of fatigue, and it is important to rule it out in patients at risk by obtaining serum glucose levels.

primary sleep disorder such as obstructive sleep apnea or restless legs syndrome.

Many clinicians order a TSH as part of the initial work-up of fatigue.

Question 22

Differential of Fatigue: Most Likely / Most Important Diagnoses

Answer 22

Depression
Depression is one of the most common causes of fatigue among adults and should be considered in all patients presenting with this complaint.
Can cause either increased sleep or decreased sleep, depending on the patient. Those with decreased sleep typically report early morning awakening with difficulty falling back asleep.

Obstructive sleep apnea
Obstructive sleep apnea is increasingly recognized as a cause of fatigue and is easily missed.
Obstructive sleep apnea (OSA) is associated with increased somnolence and unrestorative sleep, typically, but not always, in an obese patient.

Anemia
Physical findings of anemia can be difficult to gauge due to patients’ variation in skin pigmentation. Thus, pallor of the skin is not a reliable finding. One finding that has been shown to be more reliable is pale conjunctivae.

Occult malignancy
Occult malignancy should always be considered among adults with constitutional symptoms.
Occult malignancy should always be considered in cases of unexplained fatigue and is typically associated with other constitutional symptoms such as weight loss, night sweats, or fevers.

Coronary artery disease
Coronary artery disease is the leading cause of death among North American men and should be considered in adults with fatigue.

Question 23

Differential of Fatigue: Less Likely Diagnoses

Answer 23

Diabetes
Diabetes mellitus is a common cause of fatigue among adults.
Diabetic patients who intensify their glucose control report increased energy and higher health related quality of life.
Prevalence of diabetes in the general population is high and its incidence has been rising for the past decade.

Sleep restriction
Sleep restriction (i.e. physiologic fatigue) and disorders of inadequate sleep due to life circumstances, busy work schedule, jet lag, lifestyle (i.e. “ burning the candle at both ends”), and alternating shift work are very common causes of fatigue in primary care, representing up to 7% of cases.
It is important to take a detailed sleep history and history for recent events that could disrupt a patient’s sleep when evaluating a patient with fatigue.

Hypothyroidism
While fatigue or lethargy are near-universal symptoms of hypothyroidism, it is an uncommon cause of isolated fatigue.
There is no single symptom that has a high positive predictive value for the presence of hypothyroidism; however, the positive predictive value goes up with each additional symptom.
Common symptoms include cold-intolerance, weight gain, dry skin, constipation, coarse hair, and muscle cramping.
USPSTF finds insufficient evidence to recommend for or against routine screening for thyroid disease in the general population (Grade “I” recommendation).

Chronic fatigue syndrome
Chronic fatigue syndrome (CFS) is a syndrome of uncertain etiology that causes disabling levels of fatigue lasting more than six months.
The fatigue is characterized as being unrelieved by rest and worsened with exertion.
Most clinicians use the Centers for Disease Control’s (CDC’s) diagnostic criteria for CFS. This involves six months or greater of disabling fatigue that is not explained by any other medical cause plus four physical symptoms from the following list: impaired memory or concentration, post-exertional malaise, tender lymphadenopathy, sore throat, headaches, myalgias, and arthralgias.