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Core Conditions - Other > Fatigue and TATT > Flashcards

Fatigue and TATT Flashcards

1
Q

Which age groups are affected by chronic fatigue?

Who tends to be affected more?

A

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
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2
Q

What % of patients attending primary care have a complaint of fatigue?

What are precipitating factors for consultation?

A
  • 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)
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3
Q

What 2 conditions that may cause fatigue are identified in less than 3% of patients?

A
  • hypothyroidism
  • anaemia
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4
Q

How many patients presenting fatigue have tests done and how many have a diagnosis made?

A
  • 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
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5
Q

What other conditions associated with fatigue will rarely present with fatigue as a predominant complaint?

A
  • Addison’s disease
  • chronic kidney disease
  • liver failure
  • carbon monoxide poisoning
  • coeliac disease
  • sleep apnoea
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6
Q

What is the prevalence of chronic fatigue syndrome in adolescents?

How many adolescents report feeling “much more tired than usual”?

A
  • 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%
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7
Q

How does fatigue typically present?

A

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

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8
Q
A
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9
Q

What are the 7 red flags to look out for when a patient presents with fatigue?

A
  • 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
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10
Q

What is a good question to ask when taking a fatigue history?

A

“What do you think might be the cause of the problem?”

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11
Q

Why is it important to define what is meant by tiredness or fatigue?

What can fatigue actually mean?

A
  • 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
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12
Q

What questions are important to ask when noting the duration of the problem?

A
  • 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
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13
Q

What other changes might the patient have noticed alongside the fatigue which need to be asked about?

A
  • 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
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14
Q

What thing that might have been started recently is it important to ask the patient about?

A

establish whether there has been a recent start or change in medication

treatments for hypertension, especially beta-blockers, can cause lethargy

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15
Q

What bodily functions need to be asked about when taking a fatigue history?

A
  • 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
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16
Q

What might weight gain and weight loss alongside fatigue suggest?

A
  • 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
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17
Q

Why is it important to ask about polyuria or nocturia?

A
  • may indicate diabetes mellitus
  • chronic kidney disease may present with lethargy and polyuria from failure to concentrate urine
18
Q

Why is it important to ask about menstruation?

A
  • 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
19
Q

Why is it important to ask about whether bowel habit has changed?

A
  • bowels are often sluggish in depression
  • a change of bowel habit may indicate malignancy and , with it, anaemia
20
Q

Why is it important to ask about sleep?

A
  • 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
21
Q

Why is it important to ask about alcohol and what problems can this cause?

A
  • 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
22
Q

Why is it important to ask about drug taking?

What drugs are more likely to cause a problem?

A
  • 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
23
Q

Why is it important to ask about work?

What biological mechanism may be disturbed by abnormal working patterns?

A
  • 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
24
Q

What 3 stages are involved in the physical examination of a patient presenting with fatigue?

A
  • 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
25
Q

What signs should you try and look for when generally observing the patient?

A
  • 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
26
Q

Why is it really important to examine the pulse in a patient presenting with fatigue?

A
  • 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
27
Q

Why is it important to weight the patient and record their BMI?

A
  • tiredness and fatigue can occur as a result of weight gain
  • loss of weight leads to suspicion of systemic disease
28
Q

What are the differential diagnoses of someone presenting with fatigue?

A
  • 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
29
Q

What investigations and tests are done in someone with fatigue?

A
  • 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
30
Q

What is done if anaemia is seen on FBC?

A
  • 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
31
Q

What might be seen on U&Es and creatinine tests?

A

these basic tests could demonstrate unsuspected renal disease

there may be weakness and lethargy from hypokalaemia due to laxative abuse and purgation

32
Q

Why are LFTs performed and what might be seen?

A
  • the pattern of abnormal LFTs may indicate alcohol abuse
  • there may be subclinical hepatitis or metastatic disease in the liver
33
Q

What investigation may be done if coeliac disease is suspected?

A

IgA tissue transglutaminase

34
Q

What other investigations may be considered in someone presenting with fatigue, depending on the history?

A
  • 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
35
Q

How is a test for vitamin D deficiency performed?

Why might this be done?

A

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

36
Q

What may be a useful tool if the doctor thinks the patient is depressed but is uncertain?

A

the use of a validated questionnaire such as the Patient Health Questionnaire (PHQ-9)

37
Q

When might iron supplementation be considered as a treatment for fatigue?

A

it should be considered in menstruating women with unexplained fatigue who do not have anaemia but do have low ferritin levels

38
Q

What is recommended in people with obstructive sleep apnoea?

A

obstructive sleep apnoea is associated with somnolence, lethargy and poor concentration

weight loss is beneficial

39
Q

What might benefit self-reported fatigue in adults with rheumatoid arthritis?

A

physical activity and psychosocial interventions

40
Q

What has been seen to be beneficial for cancer-related fatigue?

A

aerobic exercise is beneficial for cancer-related fatigue associated with solid tumours during and post-cancer therapy

41
Q

What are factors associated with an increased likelihood of recovery, or with faster recovery, from fatigue?

A
  • 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

Core Conditions - Other (10 decks)

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