Fatigue

Question 1

Definition

Answer 1

1. Feeling of exhaustion during or at end of activity

2. Feeling of inadequate energy to begin activities

Question 2

Most common 6 causes of fatigue

Answer 2

1. Viral illness
2. Upper respiratory illness
3. Iron deficiency anemia
4. Chronic bronchitis
5. Medication
6. Depression

Question 3

Classifying fatigue

Answer 3

1. Origin
   a. Central
   b. Peripheral
2. Attributed to
   a. Physical illness
   b. Psychological
   c. Social
   d. Physiological
   e. Occupational
3. Duration
   a. Recent 1 month
   c. Chronic >6 months

Question 4

Types of clinically evaluated chronic fatigue

Answer 4

1. Chronic fatigue syndrome->Myalgic encaphalomyelitis

2. Idiopathic chronic fatige

Question 5

Common etiology (20)

Answer 5

Common
1. Psychiatric
Insomnia disorder
Depression
2. Endocrine
Hyper/hypothyroid
Diabetes melitus
3. Infection
EMV
Influenza
HIV
Tuberculosis
Toxoplasmosis
4. Drugs
Drug dependence
Alcohol
Medication induced
5. Neurological
Stroke
5. Cardiovascular/Respiratory
Chronic heart failure
AF
MI
COPD
6. Metabolic
Iron-deficiency anaemia
Iron deficiency without anaemia

Question 6

Uncommon etiology to consider

Answer 6

1. Malignancy
MDS
CML
NHL
HL
2. Psychiatric
Chronic fatigue
Restless leg 
3. Renal failure
4. GIT
Celiac
5. Metabolic
Vit B deficiency
6. Neurological
Parkinson's
7. Infections
CMV
Brucelliosis
8. Autoimmune
SLE
Primary biliary cirrhosis

Question 7

The 7 step approach to diagnosis of fatigue

Answer 7

1. Characterise the fatigue
2. Elicit presence of complaints which may suggest an underlying organic illness
3. Evaluate medication and substance use
4. Psychiatric screening
5. Ask about sleep
6. Physical examination
7. Investigations

Question 8

History (19)

Answer 8

1. Characteristics of fatigue
Duration, onset, recovery period
Impact of rest
Impact on physical activity or mental activity
Level of physical activity
Seasonality and influenza outbreak
2. Risk factors
Age, residence/travel (TB exposure)
Work with cows, uncooked meat, kitten
Immunosuppression
Occupational, recreation (ticks)
IVDU, unprotected sexual intercourse (HIV)
Sleep deprivation/sedentary
CV risk factors
Steatorrhea, weight loss (celiac)
Sore throat, lymphadenopathy
Fever, cough, runny nose (influenza)
Menomettorrhagia
Polyuria, polydipsia
Orthopnea, PND
Visual field (MS)
Heat/cold, diarrhea/constipation (thyroid)
Arthralgia, rash
Weight loss, blood in stool
Neurological symptoms
History of stroke
3. Evaluation of medication
4. Psychiatric
Anxiety
Depression
Somatisation
Substance
5. Drugs and alcohol
CAGE
AUDIT

Question 9

Physical examination

Answer 9

1. General
2. MSE
3. Pallor, tachycardia, systolic ejection murmurs: anaemia
4. Blue sclera: iron deficiency
5. Jaundice, palmar erythema, Dupuytren’s contracture: chronic liver disease
6. Goitre or thyroid nodule, dry skin, delayed deep tendon reflexes, peri-orbital puffiness, ophthalmological changes: hypothyroidism
7. Weight loss, hyper-reflexia, tachycardia, atrial fibrillation, fine tremor, goitre: hyperthyroidism
8. Hypotension, pigmentation in skin creases, scars, and buccal mucosa: Addison’s disease
9. Increased central adiposity, dry skin, reduced muscle mass and strength, visual field defects, circulatory collapse (if acute presentation): hypopituitarism
10. Lip pursing, prolonged expiration, wheezing, cyanosis: COPD
11. Pulmonary stasis, elevated jugular venous pressure, ankle oedema: heart failure
12. Lymphadenopathy and/or hepatosplenomegaly: malignancy, chronic liver disease, HIV infection, EBV, cytomegalovirus, brucellosis
13. Decreased breath sounds and presence of rales (secondary bacterial pneumonia): influenza infection
14. Pruritus, excoriations, xanthelasma: primary biliary cirrhosis
15. Red butterfly rash on the face, joint deformity: SLE
16. Tender points evaluation: fibromyalgia
17. Tremor, rigidity, bradykinesia: Parkinson’s disease
18. Loss of sensation to light touch and vibration: diabetes mellitus
19. Babinski’s reflex, ataxic nystagmus: multiple sclerosis
20. Erythema migrans, arthralgia: Lyme disease.

Question 10

Investigations

Answer 10

Initial:
FBC w/ differential
ESR if >65
UEC
LFTs
Fasting glucose
CK
CMP
TSH and free T4

Other considerations:
ECG, cardiac enzymes, CXR
Consider further testing depending on history and examination
HIV/hepatitis/EBV serology
Anti-tissue transglutaminase and enomysial antibodies