Fatigue Flashcards
what is the broad differential for fatigue?
DEAD TIRED
Fatigue:
sensation of exhaustion after usual activities OR
insufficient energy to begin usual activities.
what is some pt terminology for fatigue?
fatigue = tired = lack of
energy = excessive sleepiness = weakness =dyspnea on exertion
= depressed = and so on. A
whats a good way to get clarification for fatigue?
“What does your [fatigue] keep you from doing?” or some
other description of impact on life.
whats a high yield question for fatigue?
Is there anything in your life that
changed around the onset of your [fatigue] that might account
for your symptoms?
-Fatigue accounts for (BLANK) of patients seeking care in
primary care.
21-33%
-An estimated cost to employers exceeding (BLANK) in lost
productivity
$136 billion
- Multiple studies indicate that (BLANK) of patients in primary care
have an organic cause for their fatigue. - Laboratory tests identify as few as (BLANK) of patients source of
fatigue.
~15%
5%
what is the stepwise approach to fatigue?
what is there are no new stressors, meds, or symptoms of bleeding?
- Ask about anxiety & depression
- Obtain a sleep history
- Perform complete ROS & PE
Obtain CBC, TSH, CMP,UA, other testing depending on risk
factors. May include HCV (see below).
what are the components of sleep history?
- What time do you go to bed?
- How long does it take to you fall asleep?
- How often do you get up during the night?
- Do you nap during the day?
- Do you drink alcohol in the evening?
- Do you feel rested when you wake in the morning?
- Do you exercise? What time of day?
social history for fatigue
-Inquire about work and life stressors as well as support
system.
- Be vigilant for signs of abuse (partner/spouse) or neglect.
- Alcohol and/or drug use/abuse
- Other social determinant of health such as poverty, food
insecurity, homelessness, etc.
special pops for fatigue
Hepatitis C (HCV) screening is recommended for men who have
sex with men, anyone with a history of injection drug use or
persons born between 1945 – 1965.
what are some endocrine ROS for fatigue?
unintentional weight change (do you wear the same size
clothes?); constipation or other changes in bowel habits,
polyuria, polydipsia, polyphagia, palpitations; hair or skin
changes; cold intolerance; anorexia; etc.
what are some PE for fatigue?
VS—tachycardia or bradycardia; objective weight change
from previous visits
General: temporal or muscular wasting?
Neck: palpate thyroid
Skin: assess turgor, flaking/dryness
Hair: tug test, alopecia;
Nails for brittleness/dryness
Neuro: DTR & muscle strength
what should you look for in FH with fatigue?
DM or thyroid dysfunction
anemia PMH
renal disease
anemia ROS
Pica; Blood loss (menstrual, stool, urine); heartburn or
indigestion symptoms (peptic ulcer or esophagitis?); dental
problems (painful or difficult chewing); dizziness or syncope;
weakness; unintentional weight loss,
anemia meds
supplements that interfere with iron absorption
(H2 blockers,
anemia diet
vegan or vegetarian–plant sources of heme are less
absorbable
wellness exams to do for anemia
colonoscopy (age dependent); pelvic exam
what SH questions should you ask for anemia?
alcohol use? Poverty or isolation?
what should you look for in FH with anemia?
colon CA or other cancer
what should you do for PE for anemia?
VS –tachycardia, hypotension or orthostatic hypotension
General: general pallor or palmar pallor;
HEENT: glossitis, angular chelitis
CV: auscultate for new murmurs;
Nails: cyanosis, cap refill
Abd: complete exam to assess for masses, changes in organ
size, etc.
Rectal: fecal occult blood test
Symptoms or signs of bleeding: Obtain CBC
insomnia
Difficulty falling asleep or staying asleep or early
awakening despite the opportunity for sleep.
acute insomnia
often stress related; consider new medications and/or
medication side-effects
chronic insomnia
at least 3 nights/week for 3 months; irregular sleep
cycle (shift workers, travel, etc.)
what are some components of sleep hygiene?
x Establish a sleep pattern-go to bed and rise at the
same time every DAY
x AVOID lying in bed sleepless. After 20-30 minutes, get
out of bed; engage in mundane activities until you feel
sleepy.
x The bedroom ONLY is for sleep and sex.
x Avoid naps > 30 minutes long
x Avoid eating 3 hours before lying down
x Avoid drinking 1 hour before lying down
Treatment of Acute Insomnia
Review Sleep Hygiene
Aerobic exercise improves sleep quality
Limit Caffeine, alcohol and stimulants
Secondary treatment insomnia:
pharmacologic
- Titrate lowest effective dose with short half-life
- Limit use to 2-4 times/week
pharmocologic treatment insomnia
Benzodiazepines
Benzodiazepine receptor agonists
Tricyclic Antidepressants
Trazodone
Diphenhydramine
Primary Prevention of sleep disorder:
Healthy lifestyle that includes exercise, stress reduction and
proper sleep habits
Obstructive Sleep Apnea (OSA):
Temporarily stop or decrease
breathing during sleep for at least 10 seconds. Incidence
increases with age, obesity, M > W. ≥15 events/hour is
diagnostic for OSA.
Apnea:
Complete obstruction of airflow.
Hypopnea:
oxygen desaturation of ≥3% or arousal from sleep.
Gold standard for diagnosis: of sleep apnea
Polysomnography (aka sleep study): Combined evaluation of
sleep, breathing and movement.
-Electroencephalography (EEG) assesses brain activity
associated with stages of sleep (non-REM and REM).
-Breathing is assess by sensors that detect nasal airflow, pulse
oximetry and respiratory effort.
-ECG monitors for rate and rhythm
-Limb EMG leads analyze periodic limb movements
Treatment OSA:
-risk factor modification: weight loss, smoking cessation, avoid
alcohol or hypnotics prior to sleep
-Continuous Positive airway pressure (CPAP): pneumatically
splints upper airway throughout sleep cycle
less common treatments OSA
oral appliances that advance the
mandible and open the pharyngeal airway
-Surgery: considered second line unless there are anatomic
abnormalities
-Tracheostomy for life-threatening disease that fails other
treatments.
complications of untreated OSA
- increase of motor vehicle accidents
- hypertension
- heart failure
- impaired glucose tolerance
- increase risk of CVA
Periodic Limb Movement Disorder: aka Restless Legs
-Urge to move the legs, accompanied by the uncomfortable or
unpleasant sensation of ‘crawling’ on legs.
-Legs twitch or move every 20-24 seconds during non-rem
sleep.
-bed partner complains of kicking or restlessness
-more common after age 30
-primary cause of insomnia in 17% of patients
periodic limb movement disorder Diagnosed
during Polysomnography (sleep study)
treatment periodic limb movement disorder
dopamine agonists (pramipexole or ropinirole) OR anti-epileptics (gabapentin, pregabalin or carbamazepine)
managment of fatigue
Identification of acute stressors that may interfere with sleep
Identification of lifestyle or behaviors that disrupt sleep cycle
Screen for depression, anxiety
what are some things you must not miss with fatigue?
Anemia, Hypothyroid or Diabetes
Depression or Anxiety
Obstructive Sleep Apnea
anterior chapmans points for hypothyroid
biomechanical model hypothyroid
-Thoracic Somatic, OA, and Rib somatic dysfunctions related to
somatovisceral reflexes
Respiratory-Circulatory Model hypothyroid:
- Lymphatic Restrictions
- Mesenteric Lift (if constipated)
Neurological Model hypothyroid:
-Sympathetic innervations for head and neck: T1-4
-Sympathetic innervations for distal transverse colon to
rectum: T12-L2
-Parasympathetic innervations head and neck as well as GI tract
until proximal transverse colon: CN X-Vagus
-Parasympathetic innervations to distal transverse colon to
rectum: S2-4
-Chapman’s Points
Metabolic Model hypothyroid:
- *Hormone treatment*
- Rule out related auto immune disorders
- Consider iodine intake if needed
Behavioral Model hypothyroid:
Exercise
Proper nutrition
Therapy/psychiatric referral(depression)
posterior chapmans points for hypothyroid
Anterior Chapmans for Thyroid:
Second intercostal space
General Treatment of Chapman’s Point for Thyroid:
Firm but
gentle rotary movement over anterior and/or posterior
Champan’s Point.
Visceral Somatics for Thyroid:
Sympathetic: T1-4
Parasympathetic: CN X(Vagus)
