Download fatigue2009 - Dr. Ngo Minh

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