Unit 1 - Fatigue Flashcards
what is fatigue defined as?
difficulty or inability to initiate activity, reduced activity, difficulty with concentration/memory, and emotional instability (mental fatigue)
what are the three levels of fatigue?
recent - less than one month
prolonged - more than one month
chronic - over 6 mo
what is the most important component in evaluation of fatigue?
history
-it should determine severity and temporal pattern of fatigue
what are important parts of history that would make one think of fatigue?
- abrupt or gradual? related to other disease?
- stable, improving, or wores?
- duration and daily pattern
- factors that make it better/worse?
- impact on daily life?
- accommodations from family members (enabling instead of seeking help)?
what would a physical exam of fatigue show?
- lack of alertness, agitation, retardation, or bad grooming
- presence of lymphadenopathy
- evidence of thyroid disease
- CHF or chronic lung disease
- muscle bulk/tone/strength, DTR, nerve RXN
if DTR have slow return back to start, what fatigue-related disease does this show?
hypothyroidism
what are the most common causes of acute (recent and prolonged) fatigue?
psychiatric disorders (up to 75%), sleep disorders (up to 80%), and medication side effects
what are possible DDx for fatigue?
- psychiatric (depression, anxiety, somatization disorder, substance abuse)
- sleep disorders (insomnia, OSA, RLS, narcolepsy
- endocrine (thyroid disease, diabetes, hypoadrenalism)
- medication
- hematologic or oncologic (anemia and cancer)
- renal failure
- GI, liver disease
- cardiovascular (chronic heart failure)
- neuromuscular (myositis, MS)
- infectious
- rheumatologic (autoimmune disease)
- fatigue of unknown etiology (chronic fatigue syndrome, idiopathic)
what are must-not-miss diagnoses for fatigue? what are lab evals you need?
anemia, hypothyroidism, and diabetes
-CBC, chemistry panel, ESR, ferritin, TSH (CK only if muscle pain/weakness is present)
what are the three questions you need to answer in terms of fatigue dichotomy?
- symptoms of depression/anxiety?
- abnormal lab evaluation?
- previously undiagnosed medical conditions?
if yes to any: treat and reevaluate
if no to all: evaluate for sleep disorder
what are two diagnoses that need a sleep study
polysomnogram needed if:
- OSA risk factors/symptoms
- elderly RLS, nocturnal leg movements
what are red flags for depression/anxiety?
- history of loss
- prior depression
- postpartum state
- family history
- > 6 somatic symptoms (somatization disorder)
- +depression screen (DHQ scale)
- anxiety
- panic attacks
what are red flags for insomnia?
- difficulty initiating sleep (anxiety), staying asleep, or early awakening (depression)?
- non-restorative sleep with daytime consequences?
- frequency, duration, and precipitating events/
- sleep-wake schedule?
- attitudes toward previous treatment?
- psychiatric disorder history, substance misuse/medication use, medical illness?
- sleep apnea or restless legs?
OSA (obstructive sleep apnea) diagnosis?
daytime sleepiness (in 24% of men, 9% of women) -at least 10 seconds of cessation of ventilation, a hypopnea of at least 30% reduction in air flow for 10 seconds or longer, with at least 4% reduction in O2 saturation
what is the AHI? its different levels?
apnea-hypopnea index - total number of apneas plus hypopneas per hour
- OSA is > 5 with daytime somnolence, or > 15 regardless of symptoms
- mild = 5-14
- moderate = 15-30
- severe > 30
what are risk factors for OSA?
- obesity - 1 SD increase in BMI = 4.5 fold increase in risk
- visceral/trunkal ffat and neck circumference correlate more than BMI alone - smoking = 3x increase
- nighttime nasal congestion, if chronic = 2x increase
- anesthesia, sedative/hypnotic medications, and sleep deprivation
what are consequences of OSA?
- increased rates of MVA
- HTN, heart failure, atrial fibrillation; if longstanding, can cause cor pulmonale (takes years to develop)
- association with impaired glucose tolerance
what are clinical manifestations of hypothyroidisms?
10x more common in women than men
- weight gain, constipation, increased total and LDL cholesterol
- heat/cold intolerance
- decrease in myocardial contractility and HR
- nonpitting edema, dry skin, course fragile hair
- delayed relaxation phase of DTR
- reduced fertility, menstrual abnormalities, increased miscarriage
- thin lateral eyebrows, periorbital edema, puffy face
medications causing insomnia
- antihypertensives
- anticholinergics
- CNS stimulants
- hormones
- sympathomimetic amines
- antineoplastics
- miscellaneous (phenytoin, nicotine, levodopa, quinidine, caffeine, alcohol)
what are medications causing drowsiness?
- tricyclic antidepressants - amitriptylline, imipramine
- opioids
- benzodiazepines
- NSAIDs
- anticonvulsants - gabapentin
- alcohol
what are the symptoms of chronic fatigue syndrome?
4+ of the following gives a diagnosis (as long as not from ongoing exertion and not alleviated by rest)
- self-reported impairment in short term memory or concentration
- sore throat
- tender cervical/axillary nodes
- muscle pain
- multijoint pain w/o redness or swelling
- headaches of new pattern or severity
- unrefreshing sleep
- post-exertional malaise lasting over a day
what is treatment for chronic fatigue syndrome?
largely supportive
- antidepressants
- cognitive behavioral therapy
- graded exercise therapy
- general sleep hygiene advice
- patient education
