Fatigue

1
Fatigue

• Mark Nassim

2
A 85 year old female presents to your office
complaining of decreased energy and difficulty
concentrating. Your examination of your patient
is normal.
Which of the following investigations would you
perform?

• CBC
• HGB
• Alanine aminotransferase (SGPT)
• Aspartate aminotransferase (SGOT)
• Vitamin B12 levels
• Peripheral Blood Smear
• Iron Levels
• Electrocardiogram
• Liver Biopsy
• CK/Tnt
• Bone marrow aspiration
• HIV
• VDRL
• Random biopsy sampling for definitive tissue
  diagnosis
• Sweat Chloride test
• Chest X-Ray
• FSH/LH levels
• Bilirubin (total and direct)

X
X
X
X
X
X
X
You have completed a history and physical
evaluation and ordered the investigations you
felt appropriate. What further action would you
take?

• Exercise 30 minutes 3-4 times per week
• Smoking cessation
• Annual Fasting Blood work
• Annual Lipid Profile
• B12 supplementation
• Nutritional Counselling
• Follow up on test results

3
Defined

• The perception of being physically,
  intellectually, or emotionally exhausted
• Occurs with our without objective findings on
  physical exam, or multiple non-specific symptoms
• Can present as subjective weakness, tiredness,
  exhaustion, or decreased energy level
• Typically persists even after resting

4
Causal Conditions

• There are many, many causes for fatigue
• If you try to investigate them all, you will
• Drain the patient of all their blood for the
  tests required
• Massively irradiate the patient with all of the
  imaging required
• Spend a huge portion of your time and effort on
  one patient, running later and later while
  everyone else waits to see the doctor
• Completely waste the patients time, if you do
  not manage to kill them as a consequence of
  points 1 2
• Note that the absence of other symptoms and
  presence of a normal physical examination usually
  indicates that tests will be of value in lt 5 of
  patients.

5
Causal Conditions

• Sowhat are you supposed to do?
• You only have 15 minutes to spend!
• Perform a Focused History and Physical, followed
  by appropriate investigations

6
Step 1 Differential

• Vitamin C
• V Vascular
• I Infectious
• T Trauma
• A Anatomic
• M Metabolic
• I Idiopathic
• I Iatrogenic/Drug
• N Neoplastic
• C Congenital

7
Differential

• Vascular (cardio-pulmonary)
• Chronic congestive heart failure
• Chronic obstructive pulmonary disease
• Infectious
• Bacterial endocarditis
• Tuberculosis
• Viral (mononucleosis, hepatitis, HIV, CMV)

8
Differential

• Trauma
• Anatomic
• Connective tissue disorders
• rheumatoid arthritis
• polymyalgia rheumatica
• Gastroesophageal Reflux

9
Differential

• Metabolic
• Endocrine-metabolic
• Hypo/Hyperthyroidism
• Diabetes mellitus
• Adrenal insufficiency
• Chronic renal failure
• Chronic liver failure
• Hypercalcemia

10
Differential

• Idiopathic
• Idiopathic chronic fatigue
• Chronic fatigue syndrome

11
Differential

• Iatrogenic/Drug
• Pharmacologic
• Hypnotic
• Antihypertensives
• Antidepressants
• Drug abuse/Withdrawal (including alcohol)
• Sleep disturbances
• Lack of sleep
• Disruption
• Sleep apnea
• Periodic Leg Movements
• Bruxism

12
Differential

• Neoplastic
• Occult malignancy
• Anemia
• Congenital
• Psychologic
• Depression
• Anxiety
• Somatization

13
History

• Timing, history, pattern
• Exacerbating/mitigating factors
• Sleep patterns
• Presence of myalgias and arthralgias

14
History

• Medications
• Psychiatric history/Mood disorders/Major life
  changes
• Physical activity
• Diet/appetite/changes in weight
• EtOH, tobacco, caffeine use

15
Step 3 Physical Exam

• Perform a focused exam
• V Vascular
• I Infectious
• T Trauma
• A Anatomic
• M Metabolic
• I Idiopathic
• I Iatrogenic/Drug
• N Neoplastic
• C Congenital

16
Physical Exam

• Vascular
• CVS sounds, decreased cap refill, elevated JVP
• Respiratory Diminished breath sounds, cyanosis,
  adventitious breath sounds
• Infectious
• Source of infection
• Fever
• Signs of URTI
• Lymphadenopathy/Organomegaly
• Jaundice
• Erythema
• Exudate
• Palpable pain

17
Physical Exam

• Trauma
• Signs of Trauma
• Anatomic
• Arthritis Swollen, stiff joints
• PMR/GCA
• Shoulder and/or hip stiffness, arthalgias
• Temporal artery pain
• GERD Oral Mucosa (erythema)

18
Physical Exam

• Metabolic
• Thyroid enlarged/nodular
• Diabetes
• Skin infections, poor healing/ulcers
• Fundoscopy
• Glove and stocking syndrome
• Adrenal insufficiency
• hypotension, increased pigmentation, anorexia,
  vitiligo
• Chronic renal failure Hypertension
• Chronic liver failure
• jaundice, spider angiomas, Dupuytrens
  contracture
• Hypercalcemia
• Trousseaus sign

19
Physical Exam

• Idiopathic
• Idiopathic chronic fatigue
• Chronic fatigue syndrome
• fatigue for gt 6 months 4 or more associated
  symptoms
• Weakness (90)
• Arthralgias (90)
• Forgetfullness (90)
• Poor concentration (90)
• Emotional Lability (90)
• Confusion (90)
• Mood Swings (90)
• Low grade fever (90)
• Painful Lymph Nodes (30)

20
Physical Exam

• Iatrogenic/Drug
• Sleep Disturbances
• Dental Inspection
• TMJ pain

21
Physical Exam

• Neoplastic
• Cachexia, Lymphadenopathy, Masses, Bony pain
• Congenital
• Psychologic (interview/overall impression)
• MSIGECAPS
• History of depression
• 90 of information in the interview is non-verbal

22
Investigations

• Labwork Imaging
• V Vascular
• I Infectious
• T Trauma
• A Anatomic
• M Metabolic
• I Idiopathic
• I Iatrogenic/Drug
• N Neoplastic
• C Congenital

23
Investigations

• Vascular/Respiratory
• EKG/Stress test
• Echocardiogram
• CXR
• Infectious
• Culture (swab, sputum, urine)
• CXR
• Trauma
• Anatomic

24
Investigations

• Metabolic
• TSH
• Random and or fasting glucose
• ACTH
• Cortisol
• Creatinine
• Urea
• LFT (AST/ALT/GGT/LD)
• Albumin
• INR/PT
• Calcium
• PTH

25
Investigations

• Iatrogenic/Pharmacologic
• Ethanol
• Acetaminophen
• ASA
• BZP (non-quantifiable)
• Sleep distrubances Sleep Lab
• Neoplastic
• Imaging
• Congenital
• Psychologic

26
Management

• Conduct an effective initial plan of management
  for a patient with fatigue
• Conduct counseling and education of patients
  select patients in need of specialized care
• Follow up on investigations and appropriate
  action based on results
• Outline a plan of management that potentially
  could assist the patient realize four goals
• Accomplish activities of daily living
• Return to work
• Maintain interpersonal relationships
• Perform some type of daily exercise

27
A 85 year old female presents to your office
complaining of decreased energy and difficulty
concentrating. Your examination of your patient
is normal.
Which of the following investigations would you
perform?

• CBC
• HGB
• Alanine aminotransferase (SGPT)
• Aspartate aminotransferase (SGOT)
• Vitamin B12 levels
• Peripheral Blood Smear
• Iron Levels
• Electrocardiogram
• Liver Biopsy
• Tnt
• Bone marrow aspiration
• HIV
• VDRL
• Random biopsy sampling for definitive tissue
  diagnosis
• Sweat Chloride test
• Chest X-Ray
• FSH/LH levels
• Bilirubin (total and direct)

X
X
X
X
X
X
X
You have completed a history and physical
evaluation and ordered the investigations you
felt appropriate. What further action would you
take?

• Exercise 30 minutes 3-4 times per week
• Smoking cessation
• Annual Fasting Blood work
• Annual Lipid Profile
• B12 supplementation
• Nutritional Counselling
• Follow up on test results

X
X
X
X
28
Thank you!