Unit 1 - Fatigue

Question 1

what is fatigue defined as?

Answer 1

difficulty or inability to initiate activity, reduced activity, difficulty with concentration/memory, and emotional instability (mental fatigue)

Question 2

what are the three levels of fatigue?

Answer 2

recent - less than one month
prolonged - more than one month
chronic - over 6 mo

Question 3

what is the most important component in evaluation of fatigue?

Answer 3

history

-it should determine severity and temporal pattern of fatigue

Question 4

what are important parts of history that would make one think of fatigue?

Answer 4

1. abrupt or gradual? related to other disease?
2. stable, improving, or wores?
3. duration and daily pattern
4. factors that make it better/worse?
5. impact on daily life?
6. accommodations from family members (enabling instead of seeking help)?

Question 5

what would a physical exam of fatigue show?

Answer 5

1. lack of alertness, agitation, retardation, or bad grooming
2. presence of lymphadenopathy
3. evidence of thyroid disease
4. CHF or chronic lung disease
5. muscle bulk/tone/strength, DTR, nerve RXN

Question 6

if DTR have slow return back to start, what fatigue-related disease does this show?

Answer 6

hypothyroidism

Question 7

what are the most common causes of acute (recent and prolonged) fatigue?

Answer 7

psychiatric disorders (up to 75%), sleep disorders (up to 80%), and medication side effects

Question 8

what are possible DDx for fatigue?

Answer 8

1. psychiatric (depression, anxiety, somatization disorder, substance abuse)
2. sleep disorders (insomnia, OSA, RLS, narcolepsy
3. endocrine (thyroid disease, diabetes, hypoadrenalism)
4. medication
5. hematologic or oncologic (anemia and cancer)
6. renal failure
7. GI, liver disease
8. cardiovascular (chronic heart failure)
9. neuromuscular (myositis, MS)
10. infectious
11. rheumatologic (autoimmune disease)
12. fatigue of unknown etiology (chronic fatigue syndrome, idiopathic)

Question 9

what are must-not-miss diagnoses for fatigue? what are lab evals you need?

Answer 9

anemia, hypothyroidism, and diabetes

-CBC, chemistry panel, ESR, ferritin, TSH (CK only if muscle pain/weakness is present)

Question 10

what are the three questions you need to answer in terms of fatigue dichotomy?

Answer 10

1. symptoms of depression/anxiety?
2. abnormal lab evaluation?
3. previously undiagnosed medical conditions?
   if yes to any: treat and reevaluate
   if no to all: evaluate for sleep disorder

Question 11

what are two diagnoses that need a sleep study

Answer 11

polysomnogram needed if:

• OSA risk factors/symptoms
• elderly RLS, nocturnal leg movements

Question 12

what are red flags for depression/anxiety?

Answer 12

1. history of loss
2. prior depression
3. postpartum state
4. family history
5. > 6 somatic symptoms (somatization disorder)
6. +depression screen (DHQ scale)
7. anxiety
8. panic attacks

Question 13

what are red flags for insomnia?

Answer 13

1. difficulty initiating sleep (anxiety), staying asleep, or early awakening (depression)?
2. non-restorative sleep with daytime consequences?
3. frequency, duration, and precipitating events/
4. sleep-wake schedule?
5. attitudes toward previous treatment?
6. psychiatric disorder history, substance misuse/medication use, medical illness?
7. sleep apnea or restless legs?

Question 14

OSA (obstructive sleep apnea) diagnosis?

Answer 14

daytime sleepiness (in 24% of men, 9% of women)
-at least 10 seconds of cessation of ventilation, a hypopnea of at least 30% reduction in air flow for 10 seconds or longer, with at least 4% reduction in O2 saturation

Question 15

what is the AHI? its different levels?

Answer 15

apnea-hypopnea index - total number of apneas plus hypopneas per hour

• OSA is > 5 with daytime somnolence, or > 15 regardless of symptoms
• mild = 5-14
• moderate = 15-30
• severe > 30

Question 16

what are risk factors for OSA?

Answer 16

1. obesity - 1 SD increase in BMI = 4.5 fold increase in risk
   - visceral/trunkal ffat and neck circumference correlate more than BMI alone
2. smoking = 3x increase
3. nighttime nasal congestion, if chronic = 2x increase
4. anesthesia, sedative/hypnotic medications, and sleep deprivation

Question 17

what are consequences of OSA?

Answer 17

1. increased rates of MVA
2. HTN, heart failure, atrial fibrillation; if longstanding, can cause cor pulmonale (takes years to develop)
3. association with impaired glucose tolerance

Question 18

what are clinical manifestations of hypothyroidisms?

Answer 18

10x more common in women than men

1. weight gain, constipation, increased total and LDL cholesterol
2. heat/cold intolerance
3. decrease in myocardial contractility and HR
4. nonpitting edema, dry skin, course fragile hair
5. delayed relaxation phase of DTR
6. reduced fertility, menstrual abnormalities, increased miscarriage
7. thin lateral eyebrows, periorbital edema, puffy face

Question 19

medications causing insomnia

Answer 19

1. antihypertensives
2. anticholinergics
3. CNS stimulants
4. hormones
5. sympathomimetic amines
6. antineoplastics
7. miscellaneous (phenytoin, nicotine, levodopa, quinidine, caffeine, alcohol)

Question 20

what are medications causing drowsiness?

Answer 20

1. tricyclic antidepressants - amitriptylline, imipramine
2. opioids
3. benzodiazepines
4. NSAIDs
5. anticonvulsants - gabapentin
6. alcohol

Question 21

what are the symptoms of chronic fatigue syndrome?

Answer 21

4+ of the following gives a diagnosis (as long as not from ongoing exertion and not alleviated by rest)

1. self-reported impairment in short term memory or concentration
2. sore throat
3. tender cervical/axillary nodes
4. muscle pain
5. multijoint pain w/o redness or swelling
6. headaches of new pattern or severity
7. unrefreshing sleep
8. post-exertional malaise lasting over a day

Question 22

what is treatment for chronic fatigue syndrome?

Answer 22

largely supportive

• antidepressants
• cognitive behavioral therapy
• graded exercise therapy
• general sleep hygiene advice
• patient education