Fatigue

Done by: Nancy Ghishan Amr Lahlouh

Fatigue
Defined as the subjective complaint of tiredness or diminished energy level to the point of interfering with normal or usual activities. 1 of the top 10 chief complaints leading to family practice office visits. Peaks in ages 20-40 Women 3-4 x > men

Fatigue - Pathogenesis
Ill defined & vary depending on the underlying cause: - Psychogenic in origin - If associated with CHF, COPD, & metabolic abnormalities may be due to altered O2 & nutrient delivery peripherally. - If associated with infl conditions, such as C.T ds & infectious ds, may be due to factors released as part of the infl response.

Fatigue clinical manifestations History

Time course (Duration, onset, fluctuation, progression) Exacerbating & alleviating factors Stressors Variability in symptoms Associated symptoms Preexisting medical conditions & medication use

 Based on history, we can categorize fatigue into: - Psychogenic - Physiologic - Organic disease

Fatigue clinical manifestations History

Psychogenic Organic disease

Mostly if <6 months & fluctuates in its severity

Stressors (stressful & nonsupportive family structure or a 1 mood disturbance) Sleeping disturbance with either insomnia or early morning awakening Frequently worse in the morning & may be alleviated by activity Multiple & nonspecific complaints along with a normal P E

>6 months
Often absent

May be present but often related to the underlying disease Less in the morning & worsened with activity Fewer & more specific associated symptoms & the P E may suggest potential underlying causes

Fatigue clinical manifestations History

Physiologic: Not getting enough sleep Mothers of newborns Individuals who do shift work Athletes who overtrain Medical students

Fatigue clinical manifestations History

Red flags: Weight loss Night sweats Neuro deficits Ill-appearing

Fatigue clinical manifestations Physical examination

Complete P.E. General appearance: - patient that looks pale & sickly, with slumping posture & a sagging face physical illness - Pallor anemia - Darkening of the skin Addison disease vital signs Thyroid gland & signs of hypo/hyperthyroidism

Fatigue clinical manifestations Physical examination

Lymph nodes & joints for signs of infl. Heart & lung exam : murmers, gallops, wheezing, or rales Stigmata of alcohol or drug abuse Neurological exam neuromuscular disease

Differential Diagnosis
Psychogenic :Depression, sleep disorder, life streses, anxiety disorder, chronic fatigue
syndrome, fibromyalgia

PS VINDICATE

Sedentary : Unhealthy sedentary life. Vascular :Stroke. Infectious: Viral (mononucleosis, hepatitis), bacterial (TB), fungal, parasitic. Nutrition: Anemia (Fe def., B12 def.). Neurogenic: Myasthenia gravis, multiple sclerosis, parkinsons disease Neoplastic :Any malignancy Drugs: B-blockers, antihistamines, anticholinergic, benzodiazepines, antiepeliptics. Idiopathic Chronic illnesses: CHF, lung dis., renal failure, chronic liver dis. Autoimmune: SLE, RA, mixed connective tissue dis. Toxin :Substance abuse (alcohol). Endocrine dis. : Hypothyroidsm, DM, cushings syndrome, adrenal insufficieny, pregnancy

Investigations
Should be guided by findings on history and physical examinations and may include: CBC + differential. electrolytes and BUN, Cr. ESR. Glucose. TSH. Ferretin, B12. AST, ALT, ALP, bilirubin. Calcium, phosphate. B-HCG urinalysis. CXR, ECG. Additional tests: serologies (Lyme dis, Hepatitis B&C, HIV, ANA), PPD skin test.

Treatment
Treat the cause. No identified underlying cause:
- Physician support, REASSURANCE and follow up. - supportive counselling. - encourage patients to stay physically active to maximize function. - review all medications, OTC, herbal remedies, watching for drug-drug interactions and side effects. -Prognosis: after 1 year, 40% are no longer fatigued.

Case 1
Ahmad , a 45 year old patient , teacher, presents to the family medicine clinic complaining of overwhelming fatigue for the past 3 years. He also complains of increased sleep and headache. He is a smoker 1.5 pack/day. Past medical history: hypertensive on medication for the past 5 years. No hospitalization. No allergies On physical exam, vital signs were normal, blood pressure controlled and his systems exam turned to be normal. What is most likely cause of his fatigue? Fatigue related to his chronic hypertension and its medication Mention 2 risk factors for his fatigue? Teacher (stressful job) Smoker

Case 2
35 years old female patient comes to the clinic complaining of severe fatigue ,puffiness and round appearance of face ,increased hair growth. Her menstrual cycle is irregular. Over the last period she gained weight rapidly esp. in the face and trunk with sparing of the limbs. On physical examination : wide striae over her abdomen ,back, thighs and arms and bruising on her hands were found.
What Is the cause for the fatigue in this patient?
Cushing syndrome What are the investigations that are going to be done for her? Electrolytes esp K+

24 hour urinary free cortisol Measure blood sugar What is the treatment for such patient ?
Reducing corticosteroid use. If the cause of Cushing's syndrome is long-term use of corticosteroid medications Surgery (adrenalectomy):After the operation, you'll need to take cortisol replacement medications to provide your body with the correct amount of cortisol Radiation therapy may be used for people who aren't suitable candidates for surgery Medications : ketoconazole (Nizoral), mitotane (Lysodren) and metyrapone (Metopirone).. These drugs control excessive productions of cortisol.
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Chronic Fatigue Syndrome

prolonged and severe tiredness or weariness (fatigue) that is not relieved by rest and is not directly caused by other conditions . To be diagnosed with this condition, tiredness must be severe enough to decrease ability to participate in ordinary activities by 50%.

Epidemiology
Female more than male. More in Caucasian. Age in thirties. <5% of patients presenting with fatigue.

Etiology
unknown cause (multifactorial).

may include: infectious agents, immunological factors, neurohormonal factors, nutritional deficiency.

Diagnosis
Major Criteria + Minor Criteria & Physical Criteria OR Minor Criteria
2/2

6/11
2/3

8/11

Major Criteria
1- New onset of persistent or relapsing fatigue not previously present, sufficient to reduce daily activity by 50% or more, lasting at least 6 weeks.

2- Exclusion of other conditions which may produce similar symptoms.

2/2

Minor Criteria
1- Mild fever (37,5-38,6 C). 2- Sore Throat 3- Painful cervical or axillary lymph nodes. 4- Unexplained generalized muscle weakness. 5- Muscle discomfort or myalgias. 6- prolonged (>24hours) generalized fatigue after previously tolerated exersice. 7- generalized headache unlike previous cephalalgia. 8- migratory arthralgias without joint swelling or redness. 9- neuropsychiatric complaints: (photophobia, scotomata, foregetfulness, irritability, confusion, inability to concentrate, difficulty in thinking and depression). 10- sleep disturbance. 11- onset of main symptom complex in hours or a few days.

6/11

Physical Criteria

1- low grade fever. 2- nonexudative pharyngitis. 3- palpable or tender anterior or posterior cervical or axillary nodes (<2 cm in diameter)

2/3

Treatment
Promote sleep hygiene. Provide support and reassurance. Non-pharmacological: regular physical activity. optimal diet. psycotherapy. Pharmacological: intended for relief of symptoms (antidepressants, anxiolytics, NSAIDs, antimicrobials, antiallergy, antihypoensive)

Thank you