Fatigue

Question 1

What is a good approach to evaluating fagtigue

Answer 1

systems based approach

elicit what the patient actually means by fatigue

Question 2

define fatigue

Answer 2

1. perceived generalized weakness causing inability to initiate some activities
2. increased fatiguability reducing the ability to maintain activity
3. mental fatigue causing poor concentration, memory impairment and emotional instability

Question 3

define somnolence

Answer 3

abnormal sleepiness

Question 4

define muscle weakness

Answer 4

true muscular weakness, wherein the strength of muscles is less than expected

must differentiate this from perceived muscular weakness where the patient feels more effort is required than normal but muscle power itself is normal

Question 5

cardiopulmonary causes of fatigue

Answer 5

*post MI
*OSA
CHF
COPD
angina
critical aortic stenosis

Question 6

endocrine causes of fatigue

Answer 6

*DM
*hypothyroidism
addisons disease

Question 7

GI causes of fatigue

Answer 7

malignancy
celiac disease
chronic liver disease

Question 8

renal causes of fatigue

Answer 8

chronic kidney disease

Question 9

hematologic causes of fatigue

Answer 9

*anemia
lymphoma
leukemia
autoimmune disease

Question 10

infectious causes of fatigue

Answer 10

*viral illness
HIV
viral hepatitis
subacute bacterial endocarditis 
TB
EBV

Question 11

MSK causes of fatigue

Answer 11

rheumatoid arthritis

Question 12

neurological causes of fatigue

Answer 12

cerebrovascular disease
MS
ALS
myasthenia gravis
parkinsons disease

Question 13

psychiatric causes of fatigue

Answer 13

*depression
*anxiety
*dementia
chronic fatigue syndrome
fibromyalgia
chronic pain syndrome

Question 14

“other” causes of fatigue

Answer 14

*disordered sleep
*medication
malignancy
lupus
pregnancy

Question 15

what are the COMMON causes of fatigue

Answer 15

post MI
OSA
DM
hypothyroid
anemia
viral illness
depression
dementia
anxiety
disordered sleep
medications

Question 16

what are the LIFE THREATENING causes of fatigue

Answer 16

CHF
COPD
angina
malignancy
HIV

Question 17

some things to ask specifically on HPI for fatigue

Answer 17

impact on daily life

constitutional symptoms –weight loss, fevers, night sweats

Question 18

what meds are associated with fatigue

Answer 18

beta blockers
benzodiazepines
*also ask about OTC, herbals, CAM

Question 19

what to ask on social history for fatigue

Answer 19

substances
social stressors
intimate partner violence, abuse
recent travel or emigration  
sexual history (HIV, viral hep)

Question 20

what to ask on ROS specifically for fatigue in the following system:
CV/RESP

Answer 20

chest pain
SOB
syncope
daytime sleepiness
snoring

Question 21

what to ask on ROS specifically for fatigue in the following system:
ENDO

Answer 21

polyuria
polydipsia
dry skin
goiter
hyperpigmentation

Question 22

what to ask on ROS specifically for fatigue in the following system:
GI

Answer 22

changes in bowel pattern
black or bloody stool
abdo pain
ascites

Question 23

what to ask on ROS specifically for fatigue in the following system:
renal

Answer 23

edema
nausea
emesis
anorexia
pruritis

Question 24

what to ask on ROS specifically for fatigue in the following system:
heme

Answer 24

SOBOE
petechial rash
LAD

Question 25

what to ask on ROS specifically for fatigue in the following system: infectious

Answer 25

constitutional travel social risk factors

Question 26

what to ask on ROS specifically for fatigue in the following system: MSK

Answer 26

joint pain | swelling

Question 27

what to ask on ROS specifically for fatigue in the following system: neuro

Answer 27

``` vision changes weakness paresthesias vertigo ptosis atrophy fasciculations ```

Question 28

what to ask on ROS specifically for fatigue in the following system: psych

Answer 28

``` SIGECAPS excessive worry panic anxiety memory changes SI/HI ```

Question 29

what to ask on ROS specifically for fatigue in the following system: other

Answer 29

CAGE sleep habits rash menstrual history

Question 30

in which patients should you order a colonoscopy

Answer 30

in iron deficiency anemia in women over 50 and in any man

Question 31

how to manage fatigue if no underlying cause is found

Answer 31

BATHE approach to patient counselling ensure frequent follow up i.e monthly to monitor symptoms--continue to screen for red flags consider alternate diagnoses if its chronic and no other causes IDed ie fibromyalgia, CFS lifestyle changes pharmacologic options referral

Question 32

what is the BATHE approach to patient counselling

Answer 32

Background factors how is this Affecting you what is it about this that Troubles you most how are you Handling this Empathize and Empower --elicit patients resources and coping mechanisms

Question 33

what are some lifestyle changes that can help with fatigue

Answer 33

1. sleep hygiene--> ensure adequate sleep duration, consistent sleep/wake times, dark room, no TV/electronics in bedroom, no caffeine after noon, avoid food or exercise late in the day, avoid naps 2. stress reduction--> mindfulness exercises, reduction of work hours, hobbies, counselling 3. exercise--> regular, structured exercise i.e daily 30 min walk 4. reduce or eliminate substances

Question 34

what pharmacologic therapy may be offered for fatigue

Answer 34

a 6 week trial of SSRI may be offered if diagnosis of depression is being considered short course of treatment with hypnotic like zopiclone may be appropriate for insomnia