Download Problem Assisted Learning (PAL)

Problem Assisted Learning (PAL)
Fatigue
This PAL is based on the following objectives:
Please note that fatigue is a vague symptom; you should not adhere strictly to these objectives.
1. Mood Disorders
o List the symptoms of a patient suffering from depression after completing a
medical history.
o Discuss available psychological and prescription drug treatments for depression.
o Identify depressed patients who need special care.
2. Sleep Disorders
o List the etiologies for insomnia.
o Demonstrate the ability to perform an appropriate medical history in the context
of insomnia.
o Discuss how physical health and mental health contribute to a patient’s insomnia.
o Describe non-pharmacological measures for managing insomnia.
o Recognize the signs and symptoms of sleep apnea.
o Recognize the medico-legal implications of sleep apnea.
o Describe pharmacological options for the treatment of insomnia to the patient,
including hypnotics and sedatives.
3. Diseases/Disorders of the Endochrine System
o
o
o
o
Describe the clinical symptoms of patients suffering from hypothyroidism or
hyperthyroidism after completing a medical history and physical examination.
Identify useful tests for the diagnosis of hypothyroidism and hyperthyroidism.
Discuss the pharmacological treatment for hypothyroidism and hyperthyroidism.
Identify patients with hypothyroidism or hyperthyroidism that need specialist
consultation.
Case #1:
Discuss a general approach to fatigue:
1. What questions in the medical interview are important?
2. What aspects of physical examination are important?
3. What diagnostic tests are useful?
Case #2:
A 24 year old final year nursing student complains of one month history of musculoskeletal pain
which occurs three times a week. She has been tired for 1 month.
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1.
2.
3.
4.
What are the likely diagnoses?
What questions in medical interview do you wish to ask?
What physical examination do you wish to do?
What lab work do you require?
Case #3:
This is a 29 year old woman with very decreased energy, 10 months post-partum, who began reexperiencing migraine headaches with return of menses. Tremor x 2 months, weight loss, hair
thinner & falling out. Aware of heart beating but no extra-systoles
1.
2.
3.
4.
What are possible diagnoses?
What investigations would you do?
What treatment?
What are potential complications of treatment?
Case #4:
A 38 year old man has excessive daytime somnolence. He has had a History of trouble staying
awake in classes.
1. What are two likely diagnoses?
2. What clinical presentation distinguishes these two diagnoses?
3. What treatments would you suggest?
Case #5:
This is a 48 year old man who 5 months ago had a stent placed in his Left Anterior Descending
coronary artery for 90% stenosis. He now feels exhausted.
1. How would you approach this fatigue – what do you need to know?
Case #6:
This is a 53 year old man who presented to the office in March with complains of swollen feet
and increased shortness of breath. All winter he had been more fatigued. He noticed sweats and
a fever of 38°C at night. His medications include propranolol and digoxin 0.25 mg po daily.
1. What are the possible diagnoses?
2. What history would you like to obtain?
3. What might you expect on physical examination?
Case #7:
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A 47 year old man comes to the office complaining of feeling tired x 6-7 months. He notices
less energy with running and experiences a sensation that his “diaphragm is aching”. His only
child, 4 years old, recently died as the result of a brain tumor.
1. What diagnoses would you consider?
Case #8:
This is a 55 year old woman with complaints of fatigue throughout the day. She suffers with
initial and middle insomnia. Pain in hips, knees, ankles, feet, hands, arms, neck, low back, left
chest with respiration, weakness, shaking, forgetting words, poor memory, irritable, poor
concentration, can’t face return to work.
1. What would you look for on physical examination?
2. What are possible diagnoses?
3. What are possible treatments?
Things to cover using those cases:
Red Flags: chronic fatigue, relieved by rest
History: Chronology, old vs. recent; sleeping habits, insomnia, breaks during the day,
difficulties falling or staying asleep; medication and drug use; history of depression or stress;
changes in weight, dermatological findings, finding of blood in feces; new medications, sleeping
pills; night sweating; history of snoring, fell asleep while driving; history of an infectious
sickness and flu-like symptoms.
Physical Exam: general appearance; vital signs; weight; signs of paleness, jaundice,
dermatologic; neck and thyroid examination, lung, cardiac, abdominal, rectal and lymphatic
examination.
DDX: Often the cause is non diagnostic, especially with the young.
1. Psychiatry: depression, anxiety, substance abuse
2. Sleeping disorder: insomnia, apnea
3. Endocrine trouble: thyroid, DM (French) and hypoadrenalism
4. Medications
5. Hematological and oncological troubles
6. Renal failure
7. Liver troubles
8. Cardiac troubles
9. Pulmonary troubles: pulmonary fibrosis, pulmonary hypertension and emphysema
10. Neuromuscular troubles: MS, myocyte
11. Infectious troubles
12. Rheumatology
13. Undetermined etiology: chronic fatigue
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14. If the patient is a 50 years old male who had a car accident: DDX cardiac or sleep apnea.
Is he fit to drive?
15. If the patient is a 24 years old woman: DDX pregnant, mono, anemia and viral infection
Investigation:
 Depending on the clinical scenario, the student will be familiar to the use of the following
tests: ESR, ferritin, TSH, B12, folate, creatinine, electrolyte, glucose, liver function tests
including hepatitis serology, fecal occult blood testing, HIV testing and sleep study.
Treatments:
 Non pharmacological: treatment of fatigue is guided by the etiology if an organic cause
underlies the symptom. Student should be familiar with non-pharmacological measures to
improve on sleep such as avoiding daytime naps, avoiding afternoon use of stimulants
(caffeine, alcohol and tobacco), means of improving sleep through relaxation exercises
before sleep and enhancing sleep by means of daily exercise.
 Pharmacological: treatment of fatigue is guided by the etiology.
Article:

How a Tired Brain Can Slow Your Performance
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