fatigue & tiredness

7/31/2019 Fatigue & Tiredness

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FATIGUE & TIREDNESS

DONE BY:

Mohammed Z. Sharadqah


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Fatigue and tirdness

o Is the subjective complaint or diminished

energy level to the point that interferes with

normal and usual activities.

o One of the top 10 CC in family practice office

visits.

o 5-20% of general population have to some

degree fatigue.

o IT IS SYMPTOM which has multi-DDx.


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Why fatigue is important?

How common is Fatigue ?


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One of the top 10 complaints leading to family medicine clinic.

Why fatigue is important?

hardest term to describe

multiple differential diagnosis extensive laboratory tests

repeated office visits


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Fatigue is common.

Around 20% of people claim to have fatigue intense

enough to interfere with their having a normal life.

Physical causes are estimated at

20-60%, and

emotional causes are the other

40-80%.


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SO it is important to narrow the differentialdiagnosis in which the organic causes formminority by clear history and examination.


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Causes of fatigue

Physiological CausesResults from conditions that cause most of people to be fatigued , e.g sleep

deprivation

Common among mothers of newborn, shift workers, over-exercising andMEDDICAL STUDENTS ;)

Organic Causes

Psychogenic Causes60-80% of patients of chronic fatigue

Usually more than 6 months, and fluctuates in severity and it also can be

acute

Worse in the morning and may be decreased by activity.Patients with psycho fatigue usually have sleep disturbance


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Organic Causes

o Infections

o Endocrine : ( DM , Hypothyroidism , Hyperparathyroidism, Hypopituitarism)

o Renal : ( Acute\Chronic RF )

o Liver : ( hepatitis , cirrhosis )

o Pulmonary : ( sleep apnea , COPD )

o Cardiovascular : (CHF , Cardiomyopathy , Vulvulardisease )

o Reproductive : ( pregnancy )


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o Immunologic.

o Neuromuscular

o

Iaitrogenic : ( medications , alcoholism , drugabuse)


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Psychogenic Causes

causes :

Depression

AnxietyAdjustment reaction

Sexual dysfunction

Physical / sexual / drug / alcohol Abuse


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major depressive disorder

This disorder is characterized by the presence of the majority of

these symptoms:

1- Depressed mood most of the day, nearly every day,

2-social dysfunction and3-markedly diminished interest or pleasure in all (anhydonia),

or almost all, activities most of the day, nearly every day.

With 4 or more of following:


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Significant weight loss when not dieting or weight gain

(e.g., a change of more than 5% of body weight in a month), or

decrease or increase in appetite nearly every day Insomnia or hypersomnia nearly every day

psychomotor agitation or retardation nearly every day

fatigue or loss of energy nearly every day

feelings of worthlessness or excessive or inappropriate guiltnearly every day

diminished ability to think or concentrate, or indecisiveness,

nearly every day

Recurrent thoughts of death (not just fear of dying), recurrent

suicidal ideation without a specific plan, or a suicide attempt

or a specific plan for committing suicide.


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How to differentiate between organic and

psychological causes by history

Organic (8%) causes :

1. present more suddenly, and show a progressive course withtime.

2. Absence of stressors, family structures may be supportive.

3. Fatigue is less in the morning and worsened with activity

4. Fewer and more specific complaint, physical examinationmay show evidence of underlying disease.

5. Sleep disturbance is secondary to the disease process.

6. Reactive or secondary depression may develop


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Psychogenic (60-80%) causes :

1. Usually it takes more than six months, and fluctuates inseverity , it also can be acute

2. Identifiable stressors, non supportive family structure, or

mood disorder may be found .3. Patients with psycho fatigue usually have sleep disturbances .

4. Insomnia or early morning awakening.

5. Worse in morning and maybe decreased by activity.

6. Multiple non-specific complaints along normal physical

examination.


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Characteristics of the Psychological

Causes:

Onset:

Abrupt Duration:

Prolonged > 6 months

Progression: Progressive&

Fluctuating

Identifiable Stressor: present

Sleep disturbances: Late Morning

Associated to activity? Improved

Associated Symptoms: Non-specific

Emotional stat:

unhappiness or disappointment &

mood change

Family support:

None

Physical examination: Normal

Medication use

Characteristics of the Organic Causes:

Onset:

Insidious

Duration:Long duration

Progression: progressive

Identifiable Stressor: None

Sleep disturbances: Early

Associated to activity? Worse

Associated Symptoms: Related to

disease itself

Emotional stat:

unhappiness or disappointment

(2nddepression)

Family support:

Present

Physical examination: Related to

disease itself

Medication use


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Physical examination

Complete physical exam should be performed

Vital signs

General appearance

(Pallor, Darkening of skin, Coarse feature , sluggishness)

Thyroid gland

Examination of All lymph nodes

Examination of All joints

Lung and heart exam

Stigmata of alcohol or drug abuse

Full Neurological exam


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Lab Investigations :

History and physical exam determine the likelihood of an organic versus apsychiatric etiology

-further evaluation is needed for those with characteristics of an organic

disease: Blood tests - infection, anemic, or other problems with your blood or

nutrition

ESR: Looks for chronic diseases or inflammatory conditions

Urinalysis - diabetes, liver disease, or infection

Chem-7 - Looks at 7 common substances circulating in your blood. It

consists of4 electrolytes (sodium, potassium, chloride, and bicarbonate), 2

waste products of metabolism cleared by normally functioning kidneys

(BUN and creatinine) and the source of energy for your body's cells

(glucose).

Thyroid function tests - Looks at function of thyroid gland, too high or

too low

Pregnancy test

Serology: HIV, HBV, HCV.

Chest x-ray- Looks for infection or tumor ECG
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MANAGEMENT

specific treatment for specific causes

if etiology undetermined (most cases)

-physician support, reassurance and follow-up very important

-Aerobic exercise. Physical activity increases fitness and counteractsdepression. 30 min exercise per day.

-Diet therapy and Hydration (adding water). Water improves muscle tension,and helps to carry electrolytes.

-improving sleep patterns ( sleep hygiene therapy). The patient's sleep maybe more restful when its timing and duration are controlled.

-Pharmacotherapy (treatment with medications). The patient may be givenvarious medications to treat physical diseases or mental disorders, tocontrol pain, or to manage sleeping patterns.

-Psychotherapy. There are several different treatment approaches that helppatients manage stress, understand the motives that govern theirbehavior, or change negative ideas and negative thinking patterns.

-Physical therapy. This form of treatment helps patients improve or managefunctional impairments or disabilities.

prognosis after 1 year, 40% are no longer fatigued


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CHRONIC FATIGUE SYNDROME

*presence of unexplained, persistent fatigue, notrelieved by rest , which results in occupational ,social and personal difficulties, and with no identifiablemedical or psychological cause

*Chronic fatigue syndrome, is a disease of unknownetiology often attributed to amononucleosis infection

from the EBV .


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Epidemiology*CFS can strike at any age but the majority in their 30s*F>>M, Caucasians > other groups

Pathogenesis:multifactorial; can include

-infectious agents-immunological factors,

-neurohormonal factors


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clinical manifestations

-extreme fatigue that; is not previously present , sufficientto reduce daily activity, is not the result of ongoing effort;and is not relieved by rest;-postexertion malaise lasting more than 24 hour

-unrefreshing sleep;-substantial impairment in memory/concentration;-muscle pain; pain in multiple joints;-headaches of a new type, pattern or severity;

-sore throat;-tender neck or armpit lymph nodes.


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Symptoms and their consequences can be severe. CFScan be as disabling as multiple sclerosis, lupus, rheumatoidarthritis, congestive heart failure and similar chronic

conditions. Symptom severity varies from patient to patientand may vary over time for an individual patient.


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full history physical & mental status examination initial tests: CBC, ESR, ALT, protein, albumin, ALP, Ca

,glucose, BUN, electrolytes,creatinine, TSH, urinalysis,additional tests as clinically indicated

How to approach patient with CFS


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Diagnosis

-Since there are no physical signs that identify CFS& there are no diagnostic laboratory tests for CFS , thediagnosis is established by fulfilling both major criteriaplus6 or more of the minor criteria plus 2 or more of thephysical criteria or8 or more of 11 minor symptom criteria

Major Criteria

1.New onset of persistent or relapsing fatigue notpreviously present , sufficient to reduce daily activityby 50% or more , lasting at least 6 weeks


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2. Exclusion of other conditions which may produce

similar symptomsMinor criteria

1.Mild fever (37.5 38.6) or chills

2. Sore throat3.Painful cervical or axillary lymph nodes

4.Unexplained generalized muscle weakness

5. Muscle discomfort

6. Prolonged (>24 hours) generalized fatigue afterpreviously tolerated exercise


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7. Generalized headaches

8. Migratory arthralgias without joint swelling or redness

9. Neuropsychiatric complaints ( photophobia , forgetfulness ,irritability ..)

10. Sleep disturbances

11. Onset of main symptom complex in hours or a few daysPhysical criteria

1. Low grade fever

2. Nonexudative pharyngitis3. Palpable or tender anterior or posterior cervical or axillarylymph nodes


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Treatment of CFS

based on good physician/patient relationshipan understanding physician can limit frequent requests

for consultation and avoid demand for excessiveinvestigationstreatment is aimed at symptom relief and improved

function.a combination of drug and nondrug therapies isusually recommended.Counseling: about the illness , its pathogenesis ,

potential impact on all dimensions of life & its prognosisis extremely important .


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select medications based on target symptoms,

expected side effect profile, contraindications, patientpreference, cost muscle pain: muscle relaxants sleep dysregulation: antidepressants and get patient

to awake before 10 AM depression: antidepressants fatigue: no known treatment

Lifestyle changes, including prevention ofoverexertion, reduced stress, are frequentlyrecommended in addition to drug therapies used to treatsleep, pain and other specific symptoms.


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Recovery from CFS

Recovery rates for CFS are unclear. Improvementrates varied from 8% to 63% in a 2005 review ofpublished studies, with a median of 40% of patients

improving during follow-up. However, full recoveryfrom CFS may be rare, with an average of only 5% to10% sustaining total remission.

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