HYHO SPE3-4 Fatigue

Question 1

High Yield question to ask about fatigue?

Answer 1

Is there anything in your life that changed around the onset of your fatigue that might account for your sx?

Question 2

Broad differential for fatigue?

Answer 2

DEAD TIRED

Depression

Environment/lifestyle

Anxiety/anemia

Diabetes/endocrine

Thyroid, tumors

Infection

Rheumatologic

Endocarditis/cardiovascular

Drugs (medication or substance abuse)

Question 3

Vast majority of fatigue cases are related to what?

Answer 3

Lifestyle (caffeine, alcohol, poor sleep hygiene, inadequate sleep, shift-work, personal stressors, etc)

Question 4

Stepwise approach to fatigue

Recent stressor

New medication or substance abuse

Sign or sx of bleeding

Answer 4

Stressor => provide support, discuss sleep hygiene, reevaluate 1 mo

New medication => adjust/remove substance, reevaluate 1 mo

Sign/sx bleeding => CBC

Question 5

If recent stressor, medication, or sx of bleeding are absent, what 3 things must you obtain?

Answer 5

1. Ask about anxiety, depression
2. Obtain sleep hx
3. Perform complete ROS and PE

Obtain CBC/TSH, CMP, UA, depending on other risk factors

Question 6

7 questions to ask about sleep hx?

Answer 6

1. What time do you go to bed?
2. How long does it take you to fall asleep?
3. How often do you get up during the night?
4. Do you nap during the day?
5. Do you drink alcohol in the evening?
6. Do you feel rested when you wake in the morning?
7. Do you exercise? What time of day?

Question 7

The Hep C screen is recommended to what population?

Answer 7

MSM

Anyone with hx of injection drug use

Persons born b/w 1945-1965

Question 8

For an endocrine cause of fatigue, what would you be looking for on physical?

Answer 8

Tachy/bradycardia

Objective weight change

Temporal/muscular wasting

Palpate thyroid

Assess turgor, flaking, dry skin

Hair - alopecia

Brittle nails

Change in DTR/muscle strength

Question 9

For fatigue caused by anemia, what would you find on PE?

Answer 9

VS - tachycardia, hypotension, orthostatic hypotension

Gen - general pallor or palmar pallor

HEENT - glossitis, angular chelitis

CV - auscultate for new murmurs

Nais - cyanosis, cap refill

Abd - complete exam to assess mass, change in organ size

Rectal - fetal occult blood test

Question 10

What is the definition of chronic insomnia?

Answer 10

>3 nights a week for 3 months

Irregular sleep cycle (shift workers, travel, etc)

Question 11

Steps to sleep hygiene

Answer 11

Establish pattern - sleep/wake at the same time every day

Avoid lying in bed sleepless

Bedroom is only for sleep and sex

Avoid naps >30 min long

Avoid eating 3 hours before lying down

Avoid drinking 1 hour before lying down

Question 12

Primary prevention of sleep disorder

Answer 12

Healthy lifestyle that includes exercise, stress reduction, proper sleep habits

Question 13

Secondary tx of sleep disorder

Answer 13

Pharmacologic

Titrate lowest effective dose with short half-life

Limit use to 2-4x a week

Question 14

Definition of obstructive sleep apnea

Answer 14

Temporary stop or decrease of breathing during sleep for at least 10 seconds, >15 events/hour

Incidence increases w/ age, obesity, M>W

Question 15

Gold standard for dx of Obstructive sleep apnea

Answer 15

Polysomnography

Question 16

What dx tests other than polysomnography may assist in diagnosing?

Answer 16

EEG - brain activity

Breathing sensors for nasal airflow, pulse ox

ECG - rate/rhythm

Limb EMG - analyze periodic limb movements

Question 17

2 main tx of Obstructive Sleep Apnea

Answer 17

Risk factor modification (weight loss, smoking cessation, avoid alcohol or hypnotics prior to sleep)

CPAP

Question 18

Complications of untreated Obstructive Sleep Apnea

Answer 18

Increase motor vehicle accidents

HTN

Heart failure

Impaired glucose tolerance

Increased risk of CVA

Question 19

What is periodic limb movement disorder?

Answer 19

Restless leg syndrome

Urge to move legs, accompanied by the uncomfortable or unpleasant sensation of “crawling” on legs

Legs twitch/move every 20-24 seconds during non REM sleep

More common >30 yo

Question 20

In the management of fatigue, you must not miss what dx?

Answer 20

Anemia, hypothyroid, DM

Depression/anxiety

Obstructive sleep apnea

Question 21

Anterior chapman’s point for thyroid?

Answer 21

2nd ICS

Question 22

Viscerosomatics for thyroid?

Answer 22

Sympathetic: T1-4

Parasympathetic: CN X

Question 23

In the 5 model approach to hypothyroid, what is the main management for metabolic?

Answer 23

Hormone tx

Rule out autoimmune disorders

Consider iodine intake if needed