FATIGUE

Objectives:

1 Definition.

2 Classification

3 Causes of Fatigue

4 Practical approach of Fatigue

5 Red flags of fatigue.

6 Chronic Fatigue Syndrome

7 Treatment.

Fatigue is the subjective complaint of tiredness

or diminished energy level to the point that

interferes with normal and usual activity.

Among the most common presenting

complaints to family physicians.

Bimodal distribution by age : first peak in late

teens/ early 20s; second peak after 60. Women

present with fatigue > than men.

Classification

Acute fatigue: Fatigue of recent onset

After stressful life experiences

Because of sleep deprivation

Because of common illnesses or

conditions

Because of medication side effects

Prolonged fatigue: Fatigue lasting at least 1

month.

Chronic fatigue: Unexplained fatigue lasting at least

6 months. In most cases, physician is unable to

identify a specific cause.

Chronic fatigue syndrome – severe disabling fatigue

at least 6 months duration and a combination of

symptoms, include self-reported problems with

concentration and short-term memory, sleep

disturbances , musculoskeletal pain.

Causes of Fatigue

Psychological Physical Lifestyle causes Unexplained fatigue and Chronic fatigue syndrome

Psychological causes

60-80% of patients of chronic fatigue. Usually more than 6 months, and fluctuates in severity, it also can be acute. Identifiable stressors , non –supportive family structure, or mood disorder may be found.

Psychological causes

- Patients usually have a sleep

disturbance i.e. insomnia or early

morning awakening.

-Worse in the morning and may be

decreased by activity.

-Adjustment reaction to life changes

( death of family members, marital

status change) and substance abuse

( caffeine, alcohol, illicit drugs).

Lifestyle causes

Results from conditions that

cause most of people to

be fatigued, e.g. sleep deprivation.

Common among mothers of newborn,

shift workers, over-exercising, and

medical students

Physical causes

- Often present more abruptly,

and show a progressive course.

- The most common disorders- DM,

Acute infections, CVD, and Lung

disease.

- Medication side effects ( analgesics,

psychotropics, antihypertensives,

antihistamines.

Physical causes

- Fatigue is less in the morning and worsened with activity. -More specific complaints, physical exam., may show evidence of underlying disease. - Sleep disturbance is secondary to the disease, secondary depression may develop.

Practical approach History

Ask about : 1)Time course ( onset/ duration)

2) Aggravating and relieving factors

3) Associated symptoms (constitutional

symptoms, system-specific symptoms)

4) Impact of fatigue on relationships, work, and

leisure activities

5) Environmental stress: personal, family,

occupational, financial.

6)Medications: prescribed or OTC

7)Personal habits and behaviors: sleep,

diet, exercise, alcohol or recreational

drug use

Physical examination

Complete physical exam should be

performed.

General inspection: body habits, skin

colour , hair, sclera, nails.

Mental status

Neurologic

Musculoskeletal

Cardiovascular

Respiratory

Abdominal

Rectal

Endocrine If diagnosis

uncertain

Level one- Laboratory evaluation

Complete blood count

ESR

Chemistry panel

Thyroid testing

Pregnancy test

Age/ gender- appropriate cancer

screening ( Pap smear, mammography)

Testing suggests

etiology - further

evaluation/

management

Testing normal

Consider level two

laboratory tests .

Level two-Laboratory tests

-Chest X-ray ( adenopathy , tumors

infection, CHF)

- ECG ( silent ischemia)

-Serologies for rheumatic diseases ( RF,

ANA..)

- Drug screen for unreported substances.

- HIV, HCB ab, PPD, VDRL Testing normal

Consider Chronic

fatigue syndrome ; Or

chronic idiopathic

fatigue

Chronic Fatigue syndrome

Also called CFS/ME( Myalgic

Encephalomyelitis)

CFS includes both an encephalitic

component ( cognitive difficulties) and a

skeletal muscle component.

The cause is unknown

Diagnosis

Historical criteria:

Unexplained fatigue > 6 months

accompanied by cognitive

dysfunction

Major criteria:

Major criteria:

1. New onset persistent or relapsing

fatigue not previously present,

sufficient to reduce daily activity by

50% or more, lasting at least 6 weeks.

2. Exclusion of other conditions.

Physical criteria

1.Low grade fever

2.Non-exudative pharyngitis

3.Palpable or tender anterior or

posterior cervical or axillary nodes (2

cm in diameter)

Minor criteria:

1.Mild fever (37,5-38,6) 2.Sore throat.

3.Painful cervical or axillary lymph nodes

4.Unexplained generalized muscle weakness

5.Myalgia

6.Prolonged >24h generalized fatigue after

previously tolerated exercise

7.Generalized headaches

8.Migratory arthralgia without joint swelling or

redness.

9.Neuropsychiatric complaints ..inability to

concentration, depression, confusion.

10.Sleep disturbances

Symptoms of CFS

Percentage% Symptoms

60-95 % Low-grade fever

90 % Difficulty

concentrating

35-85 % Headaches

50-75 % Pharyngitis

30-40 % Painful Lymph

nodes

Muscle pain 20-95 %

Arthralgias 40-50%

Difficulty sleep 15-90%

Impaired

cognition

50-85%

Depression 70-85%

Anxiety 50-70%

Postexertional

malaise

50-60%

Treatment - Life style changes ( improve sleep habits)

- Graded exercise therapy

- Medications ( tricyclics or SSRIs)

-Counseling ( Supportive psychoterapy,

Cognitive-behavioral therapy) and patient

education

- Alternative complementary therapy

( acupuncture, massage)

THANK’S