Fatigue

Question 1

What should you look for first in someone you think has fatigue regarding the history? 6 things

Answer 1

1. Onset (abrupt, gradual? event or illness-related?)
2. Course (getting better, same, worse)
3. Duration and daily pattern
4. What makes it better or worse
5. Impact on daily life (working, socializing, participating in family activities)
6. Accommodations family has made to adjust

Question 2

What are a few things to look for on physical exam regarding fatigue?

Answer 2

1. General appearance (alertness, pyschomotor agitation or retardation, grooming);
2. Lymphadenopathy?
3. Evidence of thyroid disease: goiter, thyroid nodule, ophthalmologic changes?
4. Cardiopulm exam: CHF or chronic lung disease
5. Neuro exam: muscle bulk, strength, tone; DT reflexes, sensory and cranial nerve exam

Question 3

What are the three most common causes of acute fatigue?

Answer 3

Psychiatric symptoms/disorders, sleep disorders, med side effects

Question 4

What does the diagnosis include?

Answer 4

1. Psychiatric (depression, anxiety, somatization disorder, substance abuse)
2. Sleep disorders (insomnia, obstructive sleep apnea, periodic leg movements)
3. Endocrine (Thyroid disease, diabetes, hypoadrenalism)
4. Meds
   Then hematologic/oncologic, renal failure, GI/liver disease, cardiovascular (CHF), neuromuscular (myositis, MS), infectioius, rhematologic (autoimmune disease), fatigue of unknown etiology

Question 5

What three things must you rule out first in the differential regarding fatigue patients? What labs could you consider?

Answer 5

1. Anemia
2. Hypothyroidism
3. Diabetes
   TSH: rule out hypothyroid
   CBC: rule out anemia and hematologic malignancy
   ESR: look for acute illness or chronic inflammation
   Ferritin: measure iron stores
   creatine kinase: check for some sort of muscle pain/weakness

Question 6

What are three questions you want to have answered when making a diagnosis with CC of fatigue? What are the follow-ups if the answer is yes? No?

Answer 6

1. Symptoms of depression/anxiety
2. Abnormal lab evaluation
3. Previously undiagnosed med conditions?
   If yes: treat and reevaluate
   If no to all: evaluate for sleep disorder

Question 7

After asking about the three things that lead to a diagnosis, and they answered negative, what would you look at? What would you do if yes?

Answer 7

Sleep habits:
1. OSA risk factors/symptoms?
2. Elderly, restless leg syndrome, nocturnal leg movements?
If yes, do sleep study!!

Question 8

What is the apnea-hypopnea index defined as?

Answer 8

Total number of apneas plus hypopneas per hour:

OSA defined as AHI > 5 with daytime somnolence or AHI > or = 15: mild OSA is 5-14, moderate is 15-30, severe is >30

Question 9

What are risk factors for OSA?

Answer 9

1. Obesity
2. Smoking
3. Nighttime nasal congestion
4. Anesthesia, sedative/hypnotic meds, and sleep deprivation

Question 10

Possible consequences of OSA?

Answer 10

Increased MVA rates, hypertension, heart failure, a fib, perhaps impaired glucose tolerance, perhaps cor pulmonale

Question 11

What would you think of when someone says hypothyroidism?

Answer 11

1. Fatigue 2. Weight gain 3. Constipation 4. Increased total and LDL cholesterol 5. Heat/cold intolerance 6. Decreased myocardial contractility and HR 7. Nonpitting edema;
   Presentation: a fat slob who can’t take care of himself

Question 12

What meds can cause insomnia?

Answer 12

1. Antihypertensives
2. Anticholinergics
3. CNS stimulants
4. Hormones
5. Sympathomimetic amines
6. Antineoplastics
7. Miscellaneous (phenytoin, nicotine, levodopa, quinidine, caffeine, alcohol)

Question 13

What meds can cause drowsiness?

Answer 13

Tricyclic antidepressants, opioids, benzodiazepines, NSAIDs, anticonvulsants, alcohol

Question 14

What is Chronic Fatigue syndrome made up of?

Answer 14

Original definition; also, four or more of self-reported impairment with short-term memory or concentration, sore throat, tender cervical or axillary nodes, muscle pain, multijoint pain, headaches of new pattern or severity, unrefreshing sleep, post-exertional malaise >24 hours

Question 15

How can you treat CFS?

Answer 15

Largely supportive, antidepressants, cognitive behavioral therapy, graded exercise therapy, general sleep hygiene advice, patient education