Fatigue and TATT Flashcards
Which age groups are affected by chronic fatigue?
Who tends to be affected more?
chronic fatigue occurs in all age groups, including children
groups with a higher prevalence of chronic fatigue include:
- women
- minority groups
- people with lower educational and occupational statuses
What % of patients attending primary care have a complaint of fatigue?
What are precipitating factors for consultation?
- 5-7% of patients attending primary care have a primary complaint of fatigue
- precipitating factors for consultation include:
- stressful life events (e.g. difficult financial situation, bereavement, work disputes)
- physical illnesses (e.g. respiratory tract infections)
What 2 conditions that may cause fatigue are identified in less than 3% of patients?
- hypothyroidism
- anaemia
How many patients presenting fatigue have tests done and how many have a diagnosis made?
-
investigations are carried out in only half of patients complaining with fatigue
- few of these tests show abnormal results
- a diagnosis is made in less than half of patients with fatigue
- many diagnoses are descriptive - e.g. stress
What other conditions associated with fatigue will rarely present with fatigue as a predominant complaint?
- Addison’s disease
- chronic kidney disease
- liver failure
- carbon monoxide poisoning
- coeliac disease
- sleep apnoea
What is the prevalence of chronic fatigue syndrome in adolescents?
How many adolescents report feeling “much more tired than usual”?
- many adolescents have severe fatigue, but the prevalence of CFS is less common
- between 34 - 41% of adolescents report feeling “much more tired and worn out than usual”
- the prevalence of CFS in children and adolescents is between 0.11 and 4%
How does fatigue typically present?
there may be physical illness, or mental illness, or it may simply be a question of lifestyle
likely illnesses are different between older and younger patients
only a minority of patients presenting with fatigue will have a serious underlying physical cause
What are the 7 red flags to look out for when a patient presents with fatigue?
- significant weight loss
-
lymphadenopathy with signs of malignancy
- e.g. a lymph node that is non-tender, firm, hard, larger than 2cm across, progressively enlarging, supraclavicular or axillary
- any other symptoms and signs of malignancy
- e.g. haemoptysis, dysphagia, rectal bleeding, breast lump, postmenopausal bleeding
- focal neurological signs
- symptoms and signs of inflammatory arthritis, vasculitis or connective tissue disease
- symptoms and signs of cardiorespiratory disease
- e.g. angina, asthma, COPD, heart failure
- sleep apnoea
What is a good question to ask when taking a fatigue history?
“What do you think might be the cause of the problem?”
Why is it important to define what is meant by tiredness or fatigue?
What can fatigue actually mean?
- is it shortness of breath on exertion?
- is it mental exhaustion rather than physical?
- is it present all day or just towards the end of the day?
- neurological disease may present as tiredness but specific muscle groups are likely to be weak
What questions are important to ask when noting the duration of the problem?
- is it getting worse?
- was there an apparent precipitating factor?
- this could be an illness, such as glandular fever or influenza
- this could also be a social factor, such as bereavement or maybe a spouse has left the patient to cope alone with small children and a job
What other changes might the patient have noticed alongside the fatigue which need to be asked about?
- changes in weight or appetite
- polyuria and thirst
- sleep disturbance
- the ankles may be swollen at the end of the day and nocturia is more pronounced
What thing that might have been started recently is it important to ask the patient about?
establish whether there has been a recent start or change in medication
treatments for hypertension, especially beta-blockers, can cause lethargy
What bodily functions need to be asked about when taking a fatigue history?
- ask if weight is going up or down and discuss appetite
- ask if there is polyuria or nocturia
- ask about menustration, if applicable
- establish whether the bowel habit has changed
- ask about sleep
- ask about lifestyle - particularly alcohol, drugs and work
- ask whether there has been any significant event in the patient’s life that may have sparked this episode
What might weight gain and weight loss alongside fatigue suggest?
- weight gain can represent comfort eating
- thyrotoxicosis causes tiredness and weight loss is common
- poor appetite and weight loss occur in depression, especially anxiety, but may also represent systemic disease
- inflammatory disease or chronic infection cause fatigue
- fatigue is common with malignancy, but tends to accompany advanced disease rather than being a presenting feature
Why is it important to ask about polyuria or nocturia?
- may indicate diabetes mellitus
- chronic kidney disease may present with lethargy and polyuria from failure to concentrate urine
Why is it important to ask about menstruation?
- hypothyroidism may cause menorrhagia
- menorrhagia may lead to non-anaemic iron deficiency or iron-deficiency anaemia
- patient may not have noticed that her period is overdue and tiredness is due to pregnancy
Why is it important to ask about whether bowel habit has changed?
- bowels are often sluggish in depression
- a change of bowel habit may indicate malignancy and , with it, anaemia
Why is it important to ask about sleep?
- early morning waking is common in anxious depression
- in retarded depression, sleep may be excessive
- sleep may be disturbed by the demands of young children or by caring for an elderly relative
Why is it important to ask about alcohol and what problems can this cause?
- excessive consumption of alcohol may be a coping mechanism or an underlying cause
- cirrhosis or other alcohol-related problems may be developing
- if alcohol is being used as a coping mechanism, it is more likely to aggravate rather than alleviate the problem
Why is it important to ask about drug taking?
What drugs are more likely to cause a problem?
- some prescribed medications can cause fatigue
- some patients do not realise that alternative or natural remedies are just as likely to have side effects
- illicit drugs cause fatigue, especially amfetamines and cocaine
Why is it important to ask about work?
What biological mechanism may be disturbed by abnormal working patterns?
- long hours may be worked or additional caring responsibilities may be present
- shift work with frequent changes of shift between early, late and night
- constantly changing the pattern of sleeping and waking with frequent changes of shift upsets the functioning of the brain and endocrine system
What 3 stages are involved in the physical examination of a patient presenting with fatigue?
- looking at the patient and noting any observations
- examination of the pulse
- weigh the patient and record body mass index (BMI)
- further examination should be directed by clinical suspicion from history and examinations so far
What signs should you try and look for when generally observing the patient?
- is this someone who has lost weight recently and looks systemically unwell?
- are there signs of anxiety, tiredness or sleep deprivation?
- there may be ankle oedema from congestive heart failure, or dependent oedema in overweight women
Why is it really important to examine the pulse in a patient presenting with fatigue?
- a slight tachycardia can occur with anxiety and stress
- anaemia and thyrotoxicosis produce a bounding, hyperdynamic pulse
- heart failure leads to sympathetic overactivity and tachycardia
- bradycardia may be present in hypothyroidism, but is more likely in coronary heart disease
- the irregular pulse of atrial fibrillation and flutter is easily recognised
Why is it important to weight the patient and record their BMI?
- tiredness and fatigue can occur as a result of weight gain
- loss of weight leads to suspicion of systemic disease
What are the differential diagnoses of someone presenting with fatigue?
- depression
- obesity
- obstructive sleep apnoea
- poor sleep pattern, hard work, stress
- treatment with a sedative, caffeine withdrawal
- chronic fatigue syndrome
- any physical illness may be associated with fatigue, particularly:
- anaemia
- iron deficiency
- cancer
- renal disease
- liver disease
- heart failure
- thyroid disease
- diabetes
- autoimmune disease
What investigations and tests are done in someone with fatigue?
- urinalysis for glucose (diabetes) and albumin (renal disease)
- FBC to check for anaemia
- U&Es and creatinine
- random / fasting blood glucose
- LFTs
- ESR, CRP and monospot test for glandular fever
What is done if anaemia is seen on FBC?
- if anaemia is found, the cause will need investigation
- routine testing for B12 and folate is not recommended, but should be tested if FBC shows macrocytosis
What might be seen on U&Es and creatinine tests?
these basic tests could demonstrate unsuspected renal disease
there may be weakness and lethargy from hypokalaemia due to laxative abuse and purgation
Why are LFTs performed and what might be seen?
- the pattern of abnormal LFTs may indicate alcohol abuse
- there may be subclinical hepatitis or metastatic disease in the liver
What investigation may be done if coeliac disease is suspected?
IgA tissue transglutaminase
What other investigations may be considered in someone presenting with fatigue, depending on the history?
- bone biochemistry, especially if >60
- serum ferritin in women of child-bearing age
- vitamin D deficiency
- HIV if the person is at risk
- hepatitis serology if the person is at risk
- tuberculosis (chest radiography and sputum samples) if person is at risk
How is a test for vitamin D deficiency performed?
Why might this be done?
test done by bone biochemistry and serum 25-hydroxycolecalciferol concentration
if the person is at risk because of failure to spend time outdoors or regular use of sunscreens, inadequate diet or reduced gut absorption
What may be a useful tool if the doctor thinks the patient is depressed but is uncertain?
the use of a validated questionnaire such as the Patient Health Questionnaire (PHQ-9)
When might iron supplementation be considered as a treatment for fatigue?
it should be considered in menstruating women with unexplained fatigue who do not have anaemia but do have low ferritin levels
What is recommended in people with obstructive sleep apnoea?
obstructive sleep apnoea is associated with somnolence, lethargy and poor concentration
weight loss is beneficial
What might benefit self-reported fatigue in adults with rheumatoid arthritis?
physical activity and psychosocial interventions
What has been seen to be beneficial for cancer-related fatigue?
aerobic exercise is beneficial for cancer-related fatigue associated with solid tumours during and post-cancer therapy
What are factors associated with an increased likelihood of recovery, or with faster recovery, from fatigue?
- male gender
- reduced severity and duration of fatigue
- no expectation of fatigue becoming chronic
- perception of better general health
- lower levels of pain
- no carer responsibilities
- good social support
- better mental health
- willingness to accept fatigue is due to psychological factors
