Fatigue

Question 1

Ben Downer is a 50 y/o male who presents to his primary care physician for an annual visit and reports that he has been feeling tired for the past 2-3 months. What questions do you need to ask the patient about in order to further investigate a chief complaint of fatigue?

Answer 1

What does low energy mean to patient?

• Obtain a sleep history to determine if the patient is excessively sleepy during the day
• Inquire about weakness/loss of physical strength
• Explore if the patient has decreased exercise tolerance due to dyspnea on exertion
• Ask about mood symptoms
• Review medication list
• Review chronic medical conditions in past medical history that can cause fatigue

Question 2

Pt comes in with complaint of fatigue: What findings will you be looking for on your physical exam of Mr. Downer?

Answer 2

• Pallor, tachypnea • BMI, neck circumference • Jaundice • Edema seen in CHF, CKD, and Liver disease • pulmonary rales, displaced PMI, S3, JVD • Coarse hair, “hung up” reflexes, weight gain • Rash, synovitis of joints • Fever, lymphadenopathy, heart murmur

Question 3

Differential Dx for Fatigue

Answer 3

Psychiatric: depression/anxiety, substance use

Sleep disorder: OSA, insomnia

Endocrine: thyroid, DM, adrenal insufficiency

Medication Side Effects

Heme/Onc: anemia, cancer

Infections: HIV, endocarditis, TB, Lyme

Chronic Systemic Diseases of the Heart, Lung, Kidney, Liver, Neuro or Rheumatologic systems

Question 4

Test you would order in pt with fatigue (within reason of course)

Answer 4

CBC • Sleep Study • BMP • LFTs • TSH and free T4 • Cortisol • Echocardiogram • Age appropriate cancer screening ie colonoscopy, mammogram • HgA1c • Pulmonary Function Tests • Rheumatoid factor, ANA, ESR/CRP • Chest Xray • Cortisol • HIV • Urine Drug Screen

Question 5

• Fatigue means different things to different patients, thus:
• The differential diagnosis of fatigue is quite broad so a thorough history and physical exam needs to be performed on patients

Answer 5

clarify with the patient what they mean by this symptom during the history

Question 6

Pt with coarse hair, ‘hung up reflexes’ and weight gain and fatigue should be worked up for:

Answer 6

hypothyroidism

Question 7

Pt experiencing fatigue that has pallor and tachypnea should be worked up for

Answer 7

anemia

Question 8

What are the DSM-V criteria used to make the diagnosis of depression?

Answer 8

5 or 9 for at least two weeks: must include depressed mood or anhedonia

SIGECAPS

Sleep disturbance, Interest loss, Guilt or worthlessness, Energy loss or fatigue, Concentration problems, Appetite or weight change, Psychomotor agitation or retardation, Suicidal ideation

Question 9

is a chronic (2years+) low grade ie less than 5 of 9 symptoms depression

Answer 9

Persistent depressive disorder (dysthymia)

Question 10

Things to consider when working up pt for depression

Answer 10

Ensure it isn’t depression due to general medical condition ie pancreatic cancer

• Ask about past manic episodes to assess for bipolar disorder
• Normal grief/bereavement needs to be distinguished from depression

Question 11

A 31 y/o F presents c/o depression. Which of the following rules out the possibility of the patient having major depressive disorder?

A. She has recently gained weight

B. Her sleep pattern has changed so that she wakes up in the morning before her alarm rings

C. She reports being depressed since her miscarriage 2 years ago D. She was hospitalized for mania 10 years ago

E. She reports feeling like a worthless person

Answer 11

D. She was hospitalized for mania 10 years ago

Question 12

• Distinct period of elevated, expansive or irritable mood and abnormally increased energy or activity lasting 1 week •

Symptoms include distractibility, irresponsible/hedonistic, grandiose, racing thoughts, psychomotor agitation, decreased need for sleep, pressured speech

Answer 12

Manic episode

Question 13

How is hypmania different then mania?

Answer 13

• Hypomanic lasts 4 days, not impaired in functioning or psychotic, not hospitalized

Question 14

Upon completing USMLE Step I a rising M3 runs out of the testing center shouting “I’m the smartest man in the world.” His roommate reports that for two weeks he has stopped sleeping, been quite irritable and talks incessantly. He is brought in for evaluation after attempting to use his student loan money to buy a lamborghini. Which of the following is the most likely diagnosis?

A. Amphetamine intoxication

B. Bipolar disorder

C. Hyperthyroidism

D. Schizophrenia

Answer 14

B. Bipolar disorder given that the student meets criteria for a manic episode

Question 15

Whats is normal grief?

Answer 15

minor wt loss, minor sleep disturbance, milk guilty feelings, illusions or thinking you see loved one in a crowd, attempts to return to work, Crying, symptoms resolve in months to few years, don’t need anitdepressants

Question 16

Complicated grief or depression

Answer 16

sigfnificant wt loss and sleep distrubance, intentse feelings of guilt, hallcucinations or delusions, resumes few if any activities, contemplates suicide, is disabled, antidepressants are indicated

Question 17

Your 75 y/o male patient just lost his wife of 52 years to cancer. If he experiences normal bereavement/uncomplicated grief which of the following responses would be normal?

A. Initial loss of appetite with mild weight loss

B. Feelings of worthlessness

C. Threatening suicide

D. Intense disabling grief for next 2 years

E. Feelings of hopelessness

Answer 17

A. Initial loss of appetite with mild weight loss

Question 18

You dx pt with a major depressive therapy and plan to start phamacotherapy.. what musst oyu discuss with pt and document in your note?

Answer 18

• The worst possible clinical outcome in depressed patients is completed suicide
• Despite having identified many epidemiologic risk factors, suicide remains difficult to predict
• Asking about suicidal ideation will not increase a patient’s risk or “give them the idea”
• Failure to assess and document suicide risk assessment represents a significant malpractice risk

Question 19

What are risk factors associated with suicide?

Answer 19

Sex male (Caucasian at higher risk) Age teenagers or elderly Depression, Previous suicide attempts in patient or family hx, Ethanol or other drug use/addiction or impulsivity, Rational thinking absent, command hallucinations. Sickness, chronic medical condition or pain, 3+med,s Organized plan with means ie has a gun No spouse ie divorced, widowed, Social support lacking, no children or church or job

Question 20

ou call the sheriff to place your schizophrenic patient on an emergency detention and the police officer tells you he has been feeling suicidal. Which statement encapsulates the highest risk factor for suicide completion? A. His wife just left him on account of his drinking B. He is an atheist with a gun C. He is a 60 y/o male police officer D. He is feeling hopeless about his prostate cancer E. He still walks w a limp after jumping off a bridge last year and you can see noose marks on his neck from his attempted hanging last week

Answer 20

He still walks w a limp after jumping off a bridge last year and you can see noose marks on his neck from his attempted hanging last week

Question 21

Cross factors to consider when woriking up depression

Answer 21

• Cost/Insurance formulary • Ease of administration/dosing frequency • Side effect profile • Potential Drug interactions • Co-morbid medical conditions • Other approved drug indications that may apply to your patient • Toxicity in overdose in suicidal patients • Drugs used by family members

Question 22

Fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine

Answer 22

SSRIs, block 5-HT reuptaked; takes 4-6 wks

Question 23

Uses, sides od SSRIs

Answer 23

Depression, anxiety disorders, bulimia

Side effects/Toxicity Nausea/vomiting, sexual dysfunction, risk of Serotonin Syndrome

Question 24

What is Sererotin syndrome

Answer 24

• Symptoms include high fever, autonomic instability, seizures, confusion, myoclonus, flushing, treated with cyproheptadine
• May result from combining SSRI with MAOI or TCA or SNRI or meperidine or tramadol or St John’s Wort

Question 25

Your pt come in after one month on and SSRI w/out improvment, what do you do?

Answer 25

Reconsider your differential diagnosis- are you certain that Mr. Downer’s fatigue is due to depression

• Use an objective measure to evaluate for improvement PHQ-9 Patient Health Questionnaire, Hamilton Rating Scale for Depression because partial response is common and sometimes hard for patient to detect
• Search the medical literature for a randomized trial to guide your treatment

Question 26

What types of drugs are: Venlafaxine, desvenlafaxine, duloxetine, milnacipran, sibutramine and how do they work?

Answer 26

SNRIs: Inhibit serotonin and norephinephrine reuptake,

Question 27

Recommended uses for SNRIs

Answer 27

Depression, anxiety disorders, pain from diabetic peripheral neuropathy, fibromyalgia, obesity

Question 28

Side effects of SNRIs

Answer 28

Elevated blood pressure, nausea

Question 29

What type of meds are: Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine

What’s the MOA

Answer 29

TCAs, Block reuptake of Nepi and seratonin

Question 30

Recommended uses for TCAs

Answer 30

Depression, obsessive compulsive disorder, nocturnal enuresis

Question 31

Side effect profile of TCAs

Answer 31

Sedation, orthostasis, tachycardia, urinary retention, dry mouth, risk of seizures, coma, cardiac arrhythmia and death in overdose

Question 32

A 25 y/o F medical student presents complaining of fatigue. It has been getting progressively worse for 4 months and persists even if she sleeps for 14 hours at night. She also has impaired concentration, decreased appetite, and decreased pleasure consistent with a major depressive episode. She wants to try the antidepressant that most strongly inhibits norepinephrine. She should try which drug?

A. Escitalopram

B. Fluoxetine

C. Nortriptyline

D. Sertraline

E. Reserpine

Answer 32

Nortriptyline is a tricyclic antidepressant that inhibits the reuptake of norepinephrine more strongly than serotonin

Question 33

What drugs are Monamine oxidase inhibitors, why do they work to tx depression?

Answer 33

Tranlcypromine, phenelzine, isocarboxazid, selegiline,

Increases the levels of amine neuotransmitters (norepinephrine, serotonin, dopamine) by impairing degradation

Question 34

When would you put a patient on an MAOI?

What are some side effects to be aware of?

Answer 34

Atypical depression, anxiety

Side effects/Toxicity Hypertensive crisis w tyramine ingestion and serotonin syndrome, orthostasis, weight gain

Question 35

A 40 y/o M c/o persistent depression w wt gain & hypersomnia. You prescribe tranylcypromine. A few days later he is in the ER with fever, tachycardia, myoclonus, & confusion. BP 130/60. Which of the following does NOT explain his presentation?

A. He had recently been taking fluoxetine

B. He received meperidine during a colonoscopy

C. He was drinking merlot & eating parmesan

D. He took tramadol & cyclobenzaprine after throwing out his back moving a sofa

E. He uses amitriptyline for diabetic neuropathy

Answer 35

C. He was drinking merlot & eating parmesan: Eating tyramine rich foods would lead to hypertensive crisis, not serotonin syndrome

Question 36

• Approved for depression and smoking cessation • Increases norepinephrine and dopamine by inhibiting reuptake

Answer 36

Bupropion

Question 37

Side effect profile of Buproprion

Answer 37

Side effects include insomnia, headache, seizures,

• No sexual side effects, unlike the serotonergic agents

Question 38

A 13 y/o F is brought to the ER w a seizure. On exam her BMI is 15, she has lanugo and is bradycardic. She states she has been taking a friend’s antidepressant for 1 week to treat her low mood. Which drug has the girl most likely been taking?

A. Buproprion

B. Amitriptyline

C. Mirtazapine

D. Selegiline

E. Fluoxetine

Answer 38

Buproprion carries a risk of seizures especially in patients with eating disorders

Amitriptyline is a tricyclic and would have been more likely to cause a cardiac problem to prompt an ER visit

C. Mirtazapine causes sedation, constipation and weight gain

D. Selegiline is an MAOI so may lead to a hypertensive crisis if tyramine rich foods are consumed

E. Fluoxetine is an SSRI and has risk of serotonin syndrome but unlikely to cause seizures

Question 39

α 2 antagonist that increases release of norepinephrine and serotonin, 5HT2 and 5NT3 receptor antagonist

Side effects include sedation, increased appetite, weight gain and dry mouth

Answer 39

*Mirtazapine

Question 40

Approved for bipolar mania

• Narrow therapeutic window

Answer 40

Lithium

Question 41

Side effect profile of Lithium

Answer 41

Side effects include tremor, hypothyroidism, nephrogenic diabetes insipidus, teratogenic (Ebstein’s anomaly), acne, leukocytosis

Question 42

• Serotonin receptor agonist
• FDA approved for generalized anxiety disorder
• Side effects dizziness, drowsiness, headache, nausea

Answer 42

Buspirone

Question 43

An 18 y/o Female presents to Dr. Tews in the ER complaining of persistent fatigue after a recent cold. She is afebrile but appears jaundiced and has splenomegaly. Hemoglobin level is 9, mean cell hemoglobin concentration is elevated and her reticulocyte count is high. A peripheral blood smear shows…

Dx and definitive tx?

Answer 43

Splenectomy; while folate supplementation and transfusion would help symptoms of anemia, in hereditary spherocytosis splenectomy reduces hemolysis

Question 44

A 19 y/o F presents to her PCP complaining of fatigue. She had noticed that her first morning urine looks like Coca-cola. On exam she has pale conjunctiva. Labs reveal pancytopenia. The patients red blood cells are mixed with acidified normal serum and compared to normal blood cells at both room temperature and body temperature. The patient’s blood cells lyse at both temperatures while the normal blood cells do no. What is the most likely diagnosis?

Answer 44

Paroxysmal noctural hemoglobinuria defect in synthesis of cellular anchor used to hold surface proteins to cell membranes le ading to hemolysis and positive Ham test

Question 45

A 25 year old medical student presents with fatigue, fever, weight loss and nightsweats. A CT scan reveals mediastinal lymphadenopathy and the biopsy shows small number of large cells with owl eye nucleoli, multiple nuclei and an abundance of pale cytoplasm on a background of many reactive lymphocytes, macrophages, and granulocytes

Answer 45

Hodgkin’s disease characterized by presence of Reed-Sternberg cells

Question 46

A 63 yo male presents to PCP with fatigue, 10 pound weight loss, decreased vision and several severe nosebleeds. On exam hepatosplenomegaly is appreciated. Labs show increased total protein and a serum protein electrophoresis (SPEP) shows a large spike in the gamma region but skeletal survey is negative. What is the most likely diagnosis?

Answer 46

Waldenstroms macrogloulinemia monoclonal M spike and hyperviscosity syndrome (nosebleed, headache, vision disturbance)

Question 47

A 28 year old intern presents to Dr. Tews in the ED with hemoptysis, fatigue and hematuria. A renal biopsy shows a linear pattern of IgG deposition along the basement membrane upon immunofluorescence. Which of the following is most likely responsible for the intern’s disease?

Answer 47

Anti-type IV collagen antibodies are seen in Goodpasture’s syndrome and present with a nephritic syndrome

Question 48

A 23 y/o F medical students reports fatigue after recovering from recent mononucleosis infection. On physical exam she has scleral icterus, cervical lymphadenopathy and splenomegaly, and the tips of her fingers appear purple. Lab test reveal anemia and elevated reticulocyte count. Heterophile test is positive. What is the most likely diagnosis?

Answer 48

IgM mediated cold hemolytic anemia, EBV is associated w IgM antibodies directed at the i antigen on RBCs, agglutination in periphery leads to discolored fingertips

Question 49

An infectious disease physician presents with several months of fatigue, fever, weight loss, night sweat, and cough with occasional hemoptysis. On exam he is thin with enlarged nontender cervical lymphadenopathy and chest Xray shows lesion in upper lobe which is determined to be caseating granuloma with necrotic tissue and bacteria surround by macrophages and giant cells. what is the diagnosis?

Answer 49

Mycobacterium tuberculosis

Question 50

Dr. Stoner presents with fatigue and bilateral joint inflammation with pain, swelling warmth and morning stiffness in affected joints including hands and knees for several months. What are you going to prescribe her?

Answer 50

Methotrexate is appropriate to treat rheumatoid arthritis

Question 51

Your 80 year old grandmother tells you she has fatigue, fevers and weight loss with pain in her hips and shoulders that is worse in the morning. She also reports headache and jaw claudication. She has synovitis of ankles and wrist on exam. Labs show anemia and ESR of 121. What test will be diagnostic for her condition?

Answer 51

temporal artery biopsy she has symptoms of giant cell arteritis and polymyalgia rheumatica and should be started on steroids promptly

Question 52

A 55 yo with lung cancer presents with fatigue, weight loss and inability to climb stairs in his home. EMG electomyography shows impulse abnormalities w repeated stimulation. What is the mechanism of this muscle weakness?

Answer 52

IgG autoantibodies against voltage-dependent calcium channels at the neuromuscular synapse occurs in Lambert Eaton syndrome, a paraneoplastic process associated with small cell lung cancer