Approach to fatigue Flashcards
What is chronic fatigue?
A nonspecific sense of a low energy level, or the feeling that near exhaustion is reached
after relatively little exertion.
Distinguish from weakness which is a reduction in power.
What features on history should be considered.
Fever and weight loss ➡️ Infectious causes Progressive dyspnea ➡️ cardiac, pulmonary, or renal
Arthralgia ➡️ rheumatologic disorder.
Previous malignancy ➡️ Recurred or metastasized widely.
History of valvular heart disease or CMO ➡️ decompensated
Treatment (eg Graves’ disease may have resulted in hypothyroid)
Sleep apnea ➡️ common cause of unexplained fatigue
Changes in medication time course for presentation is also valuable. Indolent
presentations over months to years are more likely to be associated with slowly pro-
gressive organ failure or endocrinopathies, whereas a more rapid course over weeks
to months suggests infection or malignancy.
Time course
Indolent more likely progressive organ failure or endocrinopathies
Rapid course over weeks to months suggests infection or malignancy.
Differential diagnosis.
Infectious
Inflammatory
Infection
HIV, TB, Lyme disease, endocarditis, hepatitis, sinusitis, fungal, EBV, malaria (chronic phase)
Inflammatory
RA, polymyalgia rheumatica, chronic fatigue syn-
drome, fibromyalgia, sarcoidosis
Differential diagnosis?
Metabolic
Electrolyte imbalance
Nutritional
Metabolic
Hypothyroidism, hyperthyroidism, diabetes mellitus,Addison’s disease, hyperparathyroidism, hypogonadism, hypopituitarism (TSH, ACTH, growth hormonedeficiency), McArdle’s disease
Electrolyte imbalance
Hypercalcemia, hypokalemia, hyponatremia,
hypomagnesemia
Nutritional
Starvation, obesity, iron deficiency, vitamin B12, folicacid deficiency, vitamin C deficiency (scurvy), thiamine deficiency (beriberi)
Differential diagnosis? Cardiac Pulmonary GI Neurology Haematology Renal
Neurology ➡️Multiple sclerosis, myasthenia gravis, dementia
Cardiac ➡️Heart failure, CAD, valvular disease, cardiomyopathy
Pulmonary ➡️COPD, pulmonary hypertension, chronic pulmonary emboli, sarcoidosis
Gastrointestinal ➡️Celiac disease, Crohn’s, ulcerative colitis, chronic hepatitis, cirrhosis
Hematologic ➡️Anemia
Renal ➡️Renal failure
Differential diagnosis.
Habitual
Medication
Sleep disturbances, Sleep apnea, insomnia, restless leg syndrome
Sedatives, antihistamines, narcotics, β blockers, etc
Differential diagnosis?
Malignancy
Psychiatric
Lung, GI, breast, prostate, leukemia, lymphoma,metastases
Psychiatric Depression, alcoholism, chronic anxiety
Investigations
Laboratory testing and imaging should be guided by the history and physical exami-
nation.
FBC with differential, electrolytes, BUN, creatinine, glucose, calcium, and LFTs
CXR is heart failure, pulmonary disease, or occult malignancy that may be detected in the
lungs or bony structures.
Subsequent testing should be based on the initial results clinical assessment of the likely differential diagnoses.
Management of fatigue
Treatment should be based on the diagnosis
Metabolic, nutritional, or endocrine disorders, can be corrected
Specific treatment initiated for infections, such as TB, sinusitis, or endocarditis.
Pts with chronic conditions such as chronic obstructive pulmonary disorder (COPD), heart failure, renal failure, or liver disease may benefit from interventions that enhance organ function or correct associated metabolic problems, and it may be possible to gradually improve physical conditioning.
Cancer, fatigue may be caused by
chemotherapy or radiation and may resolve with time
Treatment of associated anemia, nutritional deficiency, hyponatremia, or hypercalcemia may increase energy levels.
Replacement therapy in endocrine deficiencies typically results in improvement.
Treatment of depression or sleep disorders, whether a primary cause of fatigue or secondary to a medical disorder, may be beneficial.
Tx sleep apnea CPAP
Withdrawal or substitution of medications that potentially contribute to fatigue should be considered. In elderly pts, appropriate medication
dose adjustments(typically lowering the dose) and restricting the regimen to only essential drugs.
What is Chronic fatigue syndrome?
Chronic fatigue syndrome (CFS) is characterized by debilitating fatigue and several associated physical, constitutional, and neuropsychological complaints.
What demographic does CFS mostly affect?
The majority of pts (~75%) are women, generally 30–45 years old.
What causes CFS?
The cause is uncertain, although clinical manifestations often follow an infectious illness (Q fever, Lyme disease, mononucleosis, or another viral illness).
Many studies have attempted, without success, to link CFS to specific infectious agents such as EBV, a retrovirus (including a murine leukemia virus–related retrovirus), or an enterovirus, and many others.
CFS might be caused by more than one
infectious agent or by postinfectious immune responses.
Physical or psychological
stress is also often identified as a precipitating factor.
Depression is present in half to
two-thirds of pts, and some experts believe that CFS is fundamentally a psychiatric
CDC CRITERIA FOR DIAGNOSIS OF CFS
Consider a diagnosis of CFS if these three criteria are met:
1 The individual has severe chronic fatigue for ≥6 consecutive months that is
not due to ongoing exertion or other medical conditions associated with
fatigue (these other conditions need to be ruled out by a doctor after diag-
nostic tests have been conducted)
2 The fatigue significantly interferes with daily activities and work.
3 The individual concurrently has four or more of the following eight
symptoms:
• postexertion malaise lasting >24 hours
• unrefreshing sleep
• significant impairment of short-term memory or concentration
• muscle pain
• multijoint pain without swelling or redness
• headaches of a new type, pattern, or severity
• tender cervical or axillary lymph nodes
• sore throat that is frequent or recurring
What is the usual course and recovery rate of CFS?
CFS does not appear to progress but typically has a protracted course. The median annual recovery rate is 5% (range, 0–31%) with an improvement rate of 39% (range, 8–63%).
Outline management of CFS?
Acknowledgement by the physician that the pt’s daily functioning is impaired.
The pt should be informed of the current
understanding of CFS (or lack thereof) and be offered general advice about disease
management.
NSAIDs alleviate headache, diffuse pain, and feverishness.
Regular and adequate sleep is important. Antihistamines or decongestants may be helpful
for symptoms of rhinitis and sinusitis.
Features of depression and anxiety may justify treatment. Nonsedating antidepressants may improve mood and disordered sleep and may attenuate the fatigue.
Cognitive behavioral therapy (CBT) and graded exercise therapy (GET) have been found to be effective treatment strategies in some pts.
