Family Medicine Flashcards
What could patients be referring to when presenting with fatigue?
- Lack of energy (physical and mental)
- Drowsiness (sleepiness not relieved by normal amounts of sleep)
- Weakness (muscle strength without a prominent mental component)
What is the Ddx for fatigue?
PS VINDICATE
- Psychogenic: depression, life stresses, anxiety disorder, chronic fatigue syndrome, fibromyalgia
- Physiologic: pregnancy, caregiving demands (young children, elderly)
- Sleep Disturbance: obstructive sleep apnea, sleep disorder, poor s-hygiene, BPH, shift work, pain
- Sedentary: unhealthy/sedentary lifestyle
- Vascular: stroke
- Infectious: viral (e.g. mono, hepatitis, HIV), bacterial (e.g. TB), fungal, parasitic
- Neoplastic: any malignancy
- Nutrition: anemia (Iron or B12 deficiency)
- Neurogenic: myasthenia gravis, multiple sclerosis, Parkinson’s disease
- Drugs: b-blockers, antihistamines, anticholinergics, benzodiazepines, antiepileptics, antidepressants
- Idiopathic: Idiopathic chronic fatigue, Chronic fatigue syndrome, Fibromyalgia
- Chronic Illness: CHF, lung disease (e.g. COPD), sarcoidosis, renal failure, chronic liver disease
- Autoimmune: SLE, RA, mixed connective tissue disease, polymyalgia rheumatica
- Toxin: substance abuse (e.g. EtOH), heavy metal
- Endocrine: hypothyroidism, diabetes mellitus, Cushing’s Syndrome, adrenal insufficiency, pregnancy
Red flags for fatigue?
Red Flags/Constitutional Symptoms: fever + weight loss + night sweats + neuro deficits + ill-appearing/cachexia
What should be asked on history if the patients reports sleepiness?
Excessive daytime sleepiness (falling asleep easier than normal, difficulty staying awake), obstructive sleep apnea symptoms (snoring, episodes of loud snoring alternating with quiet episodes of pauses in breathing, dry mouth, nasal congestion, morning headaches), Epworth Sleepiness Scale (ESS) may be used to assess the degree of sleepiness
What should be asked on history if the patients reports shortness of breath?
In patients reporting shortness of breath: history of cardiac or pulmonary disease - coughing, wheezing, and pleuritic or chest pain
Focal weakness, vision loss, or urinary incontinence may indicate
Multiple sclerosis
What should be asked on history if the patients reports weakness or lack of strength?
History of neurologic disease or myopathies, symptoms of muscle weakness during walking, household chores, exercise, and other activities of daily living
What are some possible physical exam findings for fatigue?
- Cardiac abnormalities such as murmurs, mitral regurgitation, or aortic valve pathology
- Pallor (anemia)
- Coarse skin or hair and weight gain (hypothyroidism)
- Goiter (thyroid hormone imbalance)
- Edema (heart failure, liver disease, or malnutrition)
- Poor muscle tone (advancing neurologic condition)
- Neurologic abnormalities (stroke or brain metastases)
What are some possible investigations for fatigue?
- Hematology: CBCd + electrolytes, BUN, Cr, ESR/CRP, glucose, TSH, ferritin, vitamin B12, serum protein electrophoresis, Bence-Jones protein, albumin, AST/ALT/ALP/GGT/Bilirubin, calcium, phosphate, ANA, b-HCG
- Other: urinalysis + CXR + ECG
- Serologies: Lyme disease, hepatitis B/C screen, HIV
- Mantoux Skin Test
Lifestyle changes for the treatment of fatigue?
Lifestyle changes: Sleep hygiene (no TV in bedroom, adequate sleep duration, consistent sleep/wake times), stress reduction (mindfulness exercises), exercise, EtOH/substances
Criteria for chronic fatigue syndrome?
1) New or definite onset of unexplained, clinically evaluated, persistent or relapsing chronic fatigue, not relieved by rest, which results in occupation, educational, social, or personal dysfunction
2) Concurrent presence of =>4 of the following, for 6 months
- Impairment of short-term memory/concentration, severe enough to cause decline in function
- Sore throat
- Tender cervical/axillary lymph nodes
- Myalgias
- Multi-joint arthralgias with no swelling or erythema
- New headache
- Unrefreshing sleep
- Post-exertion malaise lasting >24hour
Not otherwise explained by medical condition causing fatigue, psychiatric disorders (depression w/ psychotic or melancholic features, schizophrenia, eating disorders, substance abuse, severe obesity (BMI > 45)
Risk factors for spousal abuse
- Younger age
- Common law status
- Partner with substance abuse problem
- Marital separation
- Social isolation
- Hx of previous abuse/assault
Types of adult abuse
- Physical: hitting, pushing, biting, stab, shoot
- Emotional: threats, isolation, blackmail, humiliation, intimidation, extreme jealously
- Sexual: rape, unwanted touching
- Economic: denying funds, preventing work outside of home
Approach to adult abuse
- History: open-ended questions: “Are you in a relationship at the moment . . . How is the relationship going”
- Complete physical exam
Assessing safety risk for abused patients returning home
- What types of abuse are present
- Severity of injuries and frequency
- Nature of threats (threat of death)
- Presence of supports for victim and proximity to patient’s home
- Emergency plan in place
- Children involved
Management of adult abuse
- If willing to leave: set up safehouse, community services
- Assess level of risk to children
- Ask about level of social support
- Offer counseling/community services
- Arrange F/U
What is the target BP in most patients?
Target BP of <140/90 in most patients, <130/80 in diabetics
What is the target weight loss for obese patients
Weight loss of 5%-10% of body weight or 0.5-1 kg/wk for 6 months.
Osteoporosis Canada in conjunction with Health Canada recommend that adults age <50 years should have ____ of calcium per day. Osteoporosis Canada recommends that adults age >50 should have ____ daily.
- 1000 mg
- 1200 mg
To prevent osteoporosis and hip fractures, Osteoporosis Canada recommends ____ daily if low risk of vitamin D deficiency and ____, which may safely be increased to 2000 U, if ≥ 50 years and at moderate risk of vitamin D deficiency.
- 400-1000 IU (10-25 mcg)
- 800-1000 IU (20-50 mcg)
When does pap screening begin and when does it end?
Start screening at age 25 or 3 years after onset of sexual activity, whichever occurs later. For women aged 70 years and older who have undergone adequate screening (3 successive negative Pap test results in the last 10 years), stop screening. Q3years
When does breast cancer screening begin for women?
For women aged 50-74 years, screen every 2-3 years.
When does colorectal cancer screening begin?
50-74, FIT q2years or flexible sigmoidoscopy q5years or colonoscopy q10years
How often should a lipid profile and Framingham risk assessment be completed?
Every 5 years (if 10 year risk <5%) or yearly (if 10 year risk ≥5%) for men age 40-75 years and for women age 50-75 years
How often should diabetes screening be completed?
Screen for type 2 diabetes (T2DM) with a fasting plasma glucose (FPG) and/or A1C every 3 years after 40 years of age (or earlier if at high risk using a risk calculator)
Who should get a lose dose CT scan for lung cancer screening?
Low dose CT scan q1year (age 55-74) if risk factors (30 pack-year, currently smoke or quit less than 15 years ago) up to 3 consecutive times.
Who should get AAA screening?
Abdominal ultrasound once for males age 65-80. Do not screen men older than age 80 and do not screen women for abdominal aortic aneurysm.
To prevent fragility fractures: Screen postmenopausal women by DEXA if over __ years of age or have a history of previous fracture
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