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FATIGUE By Dr. Cuong Ngo-Minh Back to Basics April 16th 2009 Objectives LMCC • To differentiate organic from psychologic etiologies of fatigue. • To assess the impact of fatigue on work, relationship, daily function, sleep • To identify red flags (symptoms and signs) in history and physical exam to orient differential diagnosis • To investigate appropriately according to clinical findings and hypothesis about diagnosis. Refer appropriately • To create a plan of management with client. 4 goals (IADLs, return to work, maintain relationships, exercice). Definitions 1 • Fatigue: Feeling of lack of energy, tiredness, weariness described by patients as exhaustion. It is often accompanied by subjective sensation of weakness and strong desire to rest or sleep. May or not associated with other symptoms Remember: fatigue is a symptom NOT a disease • Fatigue is recent (duration < 1 month) vs chronic (lasting > 6 months) • In most cases (around 80%) is PSYCHOGENIC (eg. Not improved by rest, « tired all the time », no other symptoms or signs vs ORGANIC (20%). Can be both. Definitions 2 • Chronic fatigue syndrome: Debilitating fatigue recurrent or persistent over 6 months. DX: 1) new onset of fatigue with impairement of 50% or more of daily activities lasting more than 6 weeks 2) EXCLUSION of organic or psychiatric illness. PLUS 2 of 3 physical criteria: 1) Low grade fever 37.5-38.6C 2) Pharyngitis nonexudative 3) Palpable tender cervical-axillary nodes PLUS 6 or more of 11 symptoms: 1) Chiils or mild fever 2)Sore throat 3) Painful lymph nodes 4) Generalized muscle weakness 5) Myalgia 6) Generalized fatigue for more 24h of duration after strenuous exercice 7) Headache generalized 8) Arthralgia migratory 9) Depressive symptoms/neuropsychiatric complain 10) Sleep disturbance 11) Onset of fatigue with physical criteria within few days Differential diagnosis of fatigue • Organic etiologies (20%): Usually fatigue is worse at the END of the DAY, worse with physical activity, BETTER WITH REST. To rule out mainly by good history and physical exam. B1) Infectious (HIV, TB, mononucleosis, etc...) B2) Neoplastic/Hematologic (Anemia, leukemia-lymphoma and all other cancer according to gender and age group) B3) Metabolic-endocrine (Diabetes, Hypothyroidism, Adrenal insufficiency, Hypercalcemia, Acute renal failure, Electrolyte imbalance, etc...) B4) Inflammatory/autoimmune (Cronh, rhumatoid arthritis, PMR,...) B5) Cardio-pulmonary (Congestive heart failure, Unstable angine (think grade of dyspnea), COPD, pulmonary fibrosis, Aortic stenosis and valvulopathy...) B6) Neuromuscular (Multiple sclerosis, myasthenia gravis,...) B7) Sleep disorders (Sleep apnea, sleep deprivation, ...) B8) Medications and intoxication (B-blockers, anti-hypertensives, psychotropes, narcotics, digitalis, marijuana, ...) Differential diagnosis of fatigue • A) Psychologic/psychiatric (80%): Usually fatigue worse in MORNING (hard to get up from bed!) Depression (especially with guilt, self depreciation and poor selfesteem), anxiety, somatization. Often triggered by psycho-socioeconomic factors. History for fatigue 1 • Acute vs chronic onset? First episode or recurrent? Reason on consultation today. Disability or impact on daily life activities at work, home? Search for triggering factor (infectious contact (eg mononucleosis), change in medications, life stressors). Worse in morning or evening? Is rest helping? How is sleep (amount, timing, disruption, restorative) ? How is appetite/libido? Review of system to look for « red flags » Change of weight: weight loss (r/o neo), weight gain (r/o congestive heart failure, ascite). Change of bowels pattern (r/o neo, IBD) Diaphoresis (r/o neo), chills/fever (r/o infection), weakness (r/o neurological process), dyspnea (r/o cardio-pulmonary condition), somnolence (r/o intox-metabolic, sleep problem), blood loss? History for fatigue 2 • Past medical history (? Neo, cardiopulmonary condition, endocrine disease,anemia, psychiatric Hx...) and investigations/hospitalizations • Familial history (r/o neo, metabolic, psychiatric illness) • Medications list updated (b-blockers, cardiac meds, benzo, antipsychotic, antidepressant, narcotics, over-the-counter drugs, herbs) • Leisure drugs use (? Ivdu), alcohol, cannabis, risk for HIV • Work and psycho-socio-economic condition (recent change?) Physical examination for fatigue • Focused according to clinical hypothesis coming from history. • Cachexia? Vitals signs including Oxygen sat., glucocheck + weight, (? somnolence, ? fever, ?bradycardia, ?hyper-hypoglycemia), ? skin pallor/jaudice • Head and neck: nodes, thyroid • Chest: heart sounds, ? Murmur Lungs creps, wheezing, air entry, effusion? Abdomen: abnormal mass, ascite • Neuro exam: sign of focal deficit strength (look for assymetry), • NB. Breast or prostate exam if clinically suspiciuos of neo Investigations and management for fatigue • Investigation are done to confirm or infirm hypothesis of diagnosis CBC (for anemia, leukemia), fasting glucose (r/o diabetes), TSH (r/o hypothyroidism), Creatinine and electrolytes, CRP/ESR for inflammatory process +/- mono test. Use tests appropriately. With « absence of other symptoms and presence of normal physical examination usually indicates that tests will be of value in < 5% of patients ». Unnecessary test creates anxiety and can reinforce perception of serious disease. If needed, refer to specialists appropriately for investigations and treatment. Goal of care for fatigue • Treat specific identified cause of fatigue (if found) for return to baseline FUNCTIONAL status at work, in their daily life activities at home, exercice, interpersonal relationships • Advocate for healthy nutrition, regular physical activity (as tolerated), stress coping strategies and regular sleep schedule Truth telling (CLEO 4.4) • Chronic fatigue syndrome is diagnosis of exclusion after investigations. Empathic approach: symptoms are real for the client Non judgemental: « sidestep any consideration of the origin of the symptoms (whether psychogenic or organic) » • Ethically, duty to inform of no specific therapy, unclear diagnosis. Graded exercice and CBT (cognitive behavior therapy may help) • Do not harm principle: « physicians should guard against the temptation to prescribe empiric treatment of any type », client should be advised caution about « high-priced and potentially unsafe courses of therapy » (eg if client wants colon cleansing therapy, explain health risks he/she is exposed to ) Resources 1)Essentials of Family Medicine, 4th edition by Sloane and al. Lippincott Williams & Wilkins, pp 523-532 2) Problem-Oriented Medical Diagnosis, 6th edition by Friedman, A Little Brown spiral manual, pp 4-7 3) Practice Based Learning program from McMaster University, Module on Chronic Fatigue Syndrome, Vol 8 (10), October 2000 4) Salit IE and the Vancouver chronic fatigue syndrome consensus group. The chronic fatigue syndrome: a position paper, consensus conference, Vancouver, B.C. June 12-14, 1994. J Rheumatology 1996;23(3): 540-44