Fatigue and sleepiness

Question 1

Key history in fatigue and sleepiness

Answer 1

Duration
Sleep hygiene
Snoring
Waking up choking or gasping
Witnessed apnea
Overexertion
Stress, depression
Lifestyle changes
Shift changes at work
Weight changes
Constitutional symptoms
Symptoms of hypothyroidism
Hx of bleeding or anemia
Medications
Alcohol, caffeine and drug use

Question 2

Key physical exam in fatigue and sleepiness

Answer 2

Vital signs
ENT exam (conjunctival pallor, oropharynx/palate, lymphadenopathy, thyroid exam)
Heart, lung, abdominal, neurologic and extremity (pallor, coolness at distal extremities) exams
Consider rectal exams and stool occult blood testing

Question 3

40 yo F feeling tired, hopeless, worthless and suicidal

Answer 3

Depression
Adjustment disorder
Hypothyroidism
Anemia

CBC, TSH, Beck Depression Inventory

Question 4

44 yo M with fatigue, insomnia, nightmares about murder he witnessed at mall one year ago
+ avoids mall and going out at night

Answer 4

PTSD
Depression
Hypothyroidism

CBC, TSH, Beck Depression Inventory, urine toxicology

Question 5

55 you M with fatigue, weight loss, constipation

+ FHx of colon cancer

Answer 5

Iron deficiency anemia due to colon cancer
Hypothyroidism
Depression

Rectal exam, stool occult blood testing, colonoscopy, barium enema, CT - abdomen/pelvis, CBC, TSH, Beck Depression Inventory

Question 6

40 yo F with fatigue, weight gain, sleepiness, cold intolerance, constipation and dry skin

Answer 6

Hypothyroidism
Depression
Diabetes

CBC, TSH, FT3, FT4, Beck Depression Inventory, HbA1c, fasting glucose

Question 7

50 yo obese F with fatigue and daytime sleepiness
+ snores heavily and naps frequently but never feels refreshed
+ HTN

Answer 7

Obstructive sleep apnea
Depression
Hypothyroidism

Polysomnography, nocturnal pulse oximetry, Beck Depression Inventory, TSH, CBC

Question 8

20 yo M with fatigue, thirst, increased appetite and polyuria

Answer 8

Diabetes mellitus
Atypical depression
Primary polydipsia

HbA1c, CBC, electrolytes, BUN/Cr, UA, glucose tolerance test

Question 9

35 yo policeman with fatigue and sleepiness during day

+ changed to night shift last week

Answer 9

Shift work sleep disorder
Depression
Sleep apnea

CBC, nocturnal pulse oximetry, polysomnography