3. HYHO: Fatigue

Question 1

What is fatigue CLINICALLY?

Answer 1

1. Exhausted after usual activities
2. Not enough NRG to begin usual activities

Question 2

Fatigue can mean many things, what is a good way to diagnose if it is clinical?

Answer 2

• What does your fatigue keep you from doing? (how does it impact life)

Question 3

HIGH YEILD QUESTION for FATIGUE

Answer 3

Is there anything in your life that changed around the onset of your fatigue?

Question 4

DEAD TIRED MNEUMONIC

Answer 4

Differential for Fatigue

1. D = depression
2. E = environment/lifestyle
3. A = anxiety/anemia
4. D = DB/endocrine
5. T = tired, tumors
6. I = infection
7. R = rheumatologic
8. E = endocarditiis/ CV
9. D = drugs

Question 5

____ only ID 5% of sources of fatigue.

Answer 5

Lab tests = only 5%.

Question 6

Fatigue: what do we do next?

1. Recent stressor is ID’d =>
2. New meds/substance abuse =>
3. Sign/sx of bleeding =>

Answer 6

1. Recent stressor is ID’d => give support, discuss sleep and re-eval in 1 month
2. New meds/substance abuse => adjust or stop substance and re-eval in 1 month
3. Sign/sx of bleeding => get CBC

Question 7

If we cannot ID new stressor, pt is not on new meds/no substance abuse, bleeding, then what do we do?

Answer 7

1. Ask about anxiety/depression
2. Get sleep history
3. Perform complete ROS and PE
4. Get labs: CBC, TSH, CMP, UA, other tests

Question 8

What to ask in sleep history?

Answer 8

1. What time do you go to bed
2. How long does it take to go to bed
3. How often do you wake up at night
4. Do you nap during day?
5. Drink alcohol in evening?
6. Do you feel rested in morning
7. Do you exercise? What time?

Question 9

__________ = better sleep patterns

Answer 9

regular sleep cycle (going to bed and waking up at same time)

Question 10

• restorative sleep = _________ quality of sleep
• ___________ can be stimulating and delay onset of sleep

Answer 10

• high quality of sleep
• exercise in evening

Question 11

What should be asked in social history of fatigue?

Answer 11

1. Work/life stressors and support system
2. Look for signs of abuse/neglect
3. Alcohol/drugs
4. Poverty, food insecurity, homeless

Question 12

When should HepC screenings be done?

Answer 12

1. MSM
2. HX of injection drug
3. Born in between 1945-65

Question 13

ROS for endocrine causes of fatigue

Answer 13

1. Unintentional weight change
2. Changes in bowel habits
3. Polyuria/dipsia
4. Polyphagia
5. Palpitations
6. Hair/skin changes
7. Cold intolerance
8. Anorexia

Question 14

Anemia (=> Fatigue)

1. PMH
2. ROS
3. Medications
4. Diet

Answer 14

1. PMH = renal dx
2. ROS = PICA, blood loss, heart burn/indigestion (PUD/esophagitis), dental problems, dizziness/syncope; weakness
3. Meds = drugs that interfere with iron absorption (H2 blockers)
4. Diet = vegan/vegetarian

Question 15

Anemia (=> Fatigue)

• Wellness
• SH
• FH

Answer 15

• Wellness = colonoscopy and pelvic exam
• SH = alcohol, poverty or siolation
• FH = colon CA/cancer

Question 16

Anemia

• VS
• General
• HEENT
• CV

Answer 16

• VS = tachycardia, hypotension, orthostatic hypotension
• General = pallor
• HEENT = glossitis, angular chelitis
• CV = auscultate for new murmurs

Question 17

Anemia

• Nails
• Abdominal
• Rectal
• If bleeding present =

Answer 17

• Nails = cyanosis, cap refill
• Abdominal = complete exam to look for massess/ changes
• Rectal = fecal occult blood test
• If bleeding present = get CBC

Question 18

What is insomnia?

• • Causes of acute insomnia?
• • Definition and causes of chronic insomnia?

Answer 18

• [Difficulty falling asleep/ staying asleep] or [waking up early despite opportunity for sleep].
• Acute insomnia => stress, new meds or side effects
• Chronic insomnia => at least 3 nights/week/ 3months = irregular sleep cycle (shift workers)

Question 19

Sleep hygiene

1. If cant fall asleep for 20-30 min =>
2. Avoid naps ____ long
3. Avoid eating _____ before lying down
4. Avoid drinking ____ before lying down

Answer 19

1. Do mundane activities till sleepy
2. > 30 min
3. 3 hrs
4. 1 hr

Question 20

Tx of acute insomnia

Answer 20

1. Review sleep hygeine
2. Aerobic exercise
3. Decrease caffeine, alcohol, stimulants

Question 21

Secondary treatment of insomnia

Answer 21

Secondary treatment => pharmacologic (benzos AGO, tricyclic antidepress, trazodone, diphenhydramine)

1. @ lowest dose with short 1/2 life only 2-4 times/week

Question 22

Primary prevention of sleep disorders

Answer 22

• Healthy lifestyle (exercise, stress reduction, good sleep habits)

Question 23

Obstructive sleep apnea (OSA)

1. ​What is it?
2. RF?
3. __ events/hr = diagnostic
4. Gold standard for dx

Answer 23

• Temporarily stop or decrease breathing during sleep for at least 10 seconds.
• Increase age, obesity, men
• >15 events/hr
• Polysomnography (sleep study) = assess sleep, breathing and movement

Question 24

Difference between apnea and hypopnea

Answer 24

• Apnea = Complete obstruction of airflow.
• Hypopnea = oxygen desaturation of ≥3% or arousal from sleep

Question 25

1. _____ = dx tool used to assess brain activity associated with nREM and REM sleep 2. ________ = monitors rate and rhythm of breathing 3. ________ = analyzes period limb movements

Answer 25

1. **EEG** 2. **ECG** 3. **Limb EMG**

Question 26

**Treatment** of OSA

Answer 26

1. **Modify RF**: lose weight, stop smoking, do not take alcohol/hypnotics before bed 2. **Continous CPAP** 3. **2nd line:** surgery 4. **Life threatening:** tracheostomy

Question 27

**Complications** of untreated OSA

Answer 27

1. **MVA** 2. **HTN** 3. **HF** 4. **Impaired glucose tolerance** 5. **Increase risk of CVA**

Question 28

A **common cause of insomnia** where legs **twitch/****move**q**20-24 seconds**during**non-rem**sleep +**crawling** on legs

Answer 28

**Periodic Limb Movement Disorder**

Question 29

**_Periodic Limb Movement Disorder_** 1. More common after \_\_\_YO 2. Diagnose 3. Treatment

Answer 29

1. **30YO** 2. **Polysomnography** 3. **DA AGO (**pramipexole or ropinirole) or **ANTI-EPILEPTICS** (gabapentin, pregbalin, carbamazepine)

Question 30

Management of **fatigue**

Answer 30

1. ID acute stressors, lifestyle or behaviors that disrupt sleep 2. Screen for depression/anxiety

Question 31

When dx fatigue, what must we make sure NOT to miss?

Answer 31

1. Anemia, Hypothyroid, DB 2. Depression/anxierty 3. OSA

Question 32

**OSE for _Hypothyroid_** * Anterior Chapmans Pt: * Viscerosomatic (parasympsthetic/sympathetic):

Answer 32

* **2nd ICS** (firm, gentle movement) * VS * Sympathetic = **T1-4** * Parasympathetic = **CN 10 (Vagus)**

Question 33

**_OSE for Hypothryoid_** 1. Biomechanical 2. Respiratory-Criculatory 3. Neurologic

Answer 33

1. OA, thoracic and rib SD 2. Lymphatics and mesenteric lift if constipated 3. Viscerosomatics 1. Sympathetic 1. head and neck = T1-4 2. Distal transverse colon - rectum: T12-L2 2. Parasympathetics 1. CN X (vagus) 2. S2-4 (distal transverse colon =\> rectum) 3. Chapmans

Question 34

**OSE for Hypothryoid** * Metabolic * Behavioral

Answer 34

* Metabolic = hormone treatment; R/O AI disorders, take iodine * Behavorial = exercise, nutrition, therapy and psychiatrist if depressed