Approach To Fatigue & Tiredness

Done By:
Anmar Adel Al-Momani
Tariq Ziad Bataineh
#Family_Medicine
 Definition
Clinical fatigue incorporates three components and
patients can present complaining of:
1- Inability to initiate activity (perception of
generalized weakness, in the absence of objective
findings).
2- Reduced capacity to maintain activity (easy
fatigability).
3- Difficulty with concentration, memory, and
emotional stability (mental fatigue).
 Classification of Clinical Fatigue
based on the duration of symptoms, fatigue can be
classified into:
• Recent fatigue; symptoms lasting less than one
month.
• Prolonged fatigue; symptoms lasting for more
than one month.
• Chronic fatigue; symptoms lasting over six
months, but does not necessarily imply the
presence of the “Chronic Fatigue Syndrome”.
 Causes of Fatigue
• There are many diseases and disorders that
can cause Fatigue;
Psychological Causes; Endocrine & metabolic;
• Depression.
• Hypothyroidism.
• Anxiety.
• Somatization disorder. • Diabetes mellitus.

• Malnutrition or drug addiction. • Apathetic hyperthyroidism.

• Pituitary insufficiency.
Pharmacological Causes; • Hypercalcemia.
• Hypnotics.
• Adrenal insufficiency.
• Antihypertensive medication.
• Antidepressants. • Chronic renal failure.

• Drug abuse and drug withdrawal. • Hepatic failure.

Infectious causes; Neoplastic-hematologic;
• Endocarditis. • Occult malignancy.
• Tuberculosis. • Severe anemia.
• Mononucleosis.
• Hepatitis.
• Parasitic disease.
Connective tissue disease
• HIV infection. • Rheumatoid disease.

• Cytomegalovirus.

Disturbed sleep;
Cardiopulmonary causes; • Sleep apnea.

• Chronic heart failure. • Esophageal reflux.

• Chronic obstructive pulmonary disease. • Allergic rhinitis.

Idiopathic (diagnosis by exclusion);

• Idiopathic chronic fatigue.
• Chronic fatigue syndrome.
• Fibromyalgia.
 Psychological Causes
Community surveys have shown that:

• Psychiatric illness is present in 60 to 80 percent of patients with chronic fatigue.

• Pre-morbid psychological symptoms predispose patients to fatigue after

infections.

• The three major psychiatric illnesses were:

 major depression disorder (58 %).
I. Depression is the most common psychiatric illness associated with fatigue in
the outpatient setting.

II. Fatigue affects at least 5% of depressed patients within a 6-month period.

III. Patients with depressive disorders often complain of fatigue as part of a

symptom complex that includes loss of energy, sleep problems, and poor
appetite.

 panic disorder (14 %).

 somatization disorder (10 %).
Chronic Fatigue Recent-Onset % Condition
Fatigue

Very common Very common 15% Depression

Uncommon Common 9.6% Adjustment

Reactions

Common Very common 7.8% Sleep Disorders

and Lifestyle
issues

Very common Common 6.1% Anxiety

Uncommon Common 2.2% Substance abuse

Rare Rare 0.1% Psychosis

 Common physical causes
Chronic Fatigue Recent-onset % Disease
fatigue

Very common Very common 10.6% DM

Rare Very common 10.1% Acute Infection

Common Common 7.9% Cardiovascular Disease

Common Common 4.9% Lung disease (COPD,

Asthma)
 Less Common Physical causes
Chronic Fatigue Recent-onset fatigue % Disease

Common Uncommon 4.7% Connective tissue

disease

Common Uncommon 3.2% Malignancy

Common Common 2.8% Medication side effects

Uncommon Common 2.8% Anemia

Common Uncommon 2.6% Hypothyroidism
Uncommon Rare 1.8% Chronic Infection (TB,
HIV)

Rare Rare 1.6% GI causes

 Other causes:
• Adrenal insufficiency .

• Hypopituitarism: Be especially suspicious if there is a history of

hypotension (e.g., postpartum) or of headaches or breast discharge
(in women, suggesting prolactinoma) .

• Hypercalcemia: serum calcium in laboratory evaluation of fatigue .

• Carbon monoxide poisoning : Symptoms are often vague; headache

is common. Suspect if using wood stove or gas heater in the winter.

• Intimate partner violence..

 Lifestyle causes
Examples include:

• Increased physical exertion over the patient's established

habits.
• Inadequate rest.
• Sleep Pattern disruption.
• Effects of recent surgery or trauma.
• Some environmental stresses: Excessive noise, heat and Cold.
• Sedentary Lifestyle compared to physically active life
(exercise).
 Chronic Fatigue Syndrome
• Over time, with careful follow-up, the number of undiagnosed
patients should be quite small, but nonetheless some will
remain undiagnosed. (Unexplained Fatigue)
• Others will meet the criteria for chronic fatigue syndrome
(CFS).

CDC criteria for Chronic fatigue syndrome (CFS):

-The Major criteria (Must meet both)
-Minor Criteria (8/11 or 6/11 + 2 physical findings)
Major criteria
1. New onset of fatigue lasting six months, severe enough to reduce daily activity to
less than 50 percent of the patient's premorbid activity level.

2. The exclusion of other conditions that can produce fatigue.

Minor criteria
Symptom criteria
1. Low grade fever: temperature 37.5 to 38.6°C orally or chills
2. Sore throat
3. Painful cervical or axillary lymph nodes
4. Generalized muscle weakness
5. Muscle pain
6. Postexertional fatigue lasting more than 24 hours
7. Generalized headaches
8. Migratory arthralgias
9. Neuropsychological complaints (photophobia, transient visual scotomata, forgetfulness, excessive irritability, confusion,
difficulty thinking, inability to concentrate, or depression)

10. Sleep disturbance

11. Acute onset of symptoms over a few hours to a few days

Physical criteria (determined by the physician on two occasions at least two months apart)

1. Low-grade fever
2. Nonexudative pharyngitis
3. Palpable cervical or axillary lymph nodes up to 2 cm in diameter
 Management Of Chronic Fatigue
Syndrome
• Because most cases of chronic fatigue
syndrome (CFS) may be due to a viral
infection, no uniformly effective therapy exists
for CFS. Trials of antiviral agents have been
ineffective in relieving the symptoms of CFS.
• In patients with elevated C pneumoniae levels,
particularly those with increased
immunoglobulin M (IgM) titers, antichlamydial
therapy may be effective. No special diet or
vitamin supplements are effective.
If no specific treatment yet exists, why
should we make a Diagnosis?!
I. Reducing unnecessary investigations
II. Providing an explanation to the patient.
III. Providing support for disability (in some
cases).
IV. Identifying an approach to treatment.
Organic Vs. Psychological causes of Fatigue
 Clinical
Approach to Fatigue
• Clinical History.

• Physical Examination.

• Accordingly, Investigations.

Note: The evaluation of fatigue will often take more than

one visit, and will involve an extensive history and physical
examination, rather than the focused examination that is
used for some other presenting complaints.
#Family_Medicine
 Clinical History
• Systemic Review.

• Medical History.

• Psychosocial History.

• Family History.

• Occupational History.

• Medication history.
• Fatigue:
Patient's main complaints are: weakness,
depleted energy, tiredness, and/or exhaustion.
Look For: Physical and Psychological Causes of
fatigue.

• Daytime sleepiness:
Patient's main complaints are: drowsiness, a
tendency to fall asleep at inappropriate times,
and/or decreased alertness at work.
Look For: Causes of Sleep disorder.
Elements of the history that suggest a psychological diagnosis

• A history of a dysfunctional family setting and/or a previous

history of functional health problems.

• The onset of the fatigue is associated with stress and

accompanied by multiple, nonspecific symptoms.

• The tiredness is worse in the morning and fluctuates rather

than progresses in intensity over the course of the day.

• The fatigue is relieved by physical activity.

 Key Elements of the History for Fatigue
Purpose Question/maneuver

Screen for psychological and lifestyle Positive Psychological Hx

causes

Medication side effects Medication Use

Look for acute infection Fever

Look for cancer and HIV disease Weight Loss

Anemia Pallor

TB, HIV, COPD Cough

Look for CTD Joint pain/Inflammation

Heart failure, COPD Exertional Dyspnea

Look for Red Flags

 Red Flags
Suggested Diagnosis
Major depressive episode; high suicide
risk
Withdrawal syndrome
Life-threatening infection
Severe anemia due to blood loss or
hemolysis
Acquired Immunodeficiency Syndrome
(AIDS)
Severe left-sided congestive heart failure
Red flag
Suicidal ideation, marked social
withdrawal
History of alcohol, narcotic, or
psychotropic drug abuse with recent
discontinuation of use
Fever >39.5°C, chills, hypotension, and/or
neck stiffness
Recent onset of severe or worsening
fatigue, especially if accompanied by
pallor, jaundice, or a history of recent
blood loss
Gradual onset of fatigue in a patient with
prominent risk factors for HIV exposure
Orthopnea, edema, cardiomegaly,
auscultatory crackles
 Suggested Diagnosis Red flag
Poorly controlled diabetes Polydipsia, polyuria

Pulmonary hypertension due to severe Peripheral edema, especially in the setting

obstructive sleep apnea with cor pulmonale of chronic dyspnea and hypoxemia or
hypercapnia

Significant accident risk; possible narcolepsy Falling asleep during activities, in

conversation, or while driving
 Physical examination
physical examination is important to exclude some specific causes
of fatigue and also helps to establish the doctor-patient relationship,
assuring the patient that his or her complaint is a concern worth
investigating. The physical examination should note:
i. General appearance: level of alertness, psychomotor agitation
or retardation, grooming.
ii. Presence of lymphadenopathy.
iii. Evidence of thyroid disease: goiter, thyroid nodule,
ophthalmologic changes.
iv. tendon reflexes: sensory and cranial nerve evaluation.
v. Cardiopulmonary examination: signs of congestive heart
failure and chronic lung disease.
vi. Neurologic examination: muscle bulk, tone, and strength.
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Key Points in Physical Examination
:Think About Findings

malignancy, Infections Lymphadenopathy/HepatoSplenomegaly

Hypothyroidism Thyromegaly, Dry skin, delayed reflexes

Acute URTIs ENT examination

COPD, HF, Pneumonia Cardiopulmonary examination

fibromyalgia Widespread pain, trigger points

 Diagnostic workup
Reasonable initial studies to obtain include:

• Complete blood count with differential (CBC).

• Erythrocyte sedimentation rate (ESR), ferritin.
• Chemistry screen (including electrolytes, glucose, renal and
liver function tests).
• Thyroid stimulating hormone (TSH).
• Creatine kinase (CK), if pain or muscle weakness is present.
This combination of tests will help to confirm or rule out the
most common physical causes of fatigue.
HIV testing and PPD (purified protein derivative)
should be considered if appropriate based on
patient’s history.
We do not suggest routine testing for:
I. Infection (i.e. EBV, CMV, or Lyme titers).
II. Immunological deficiency (i.e. immunoglobulins).
III. Inflammatory disease (ANA or rheumatoid
factor).
IV. Antibody studies for celiac disease, or assay for
CK.
without other features suggesting related
conditions.
Recommended Diagnostic strategy
The doctor-patient relationship is of profound importance. Two-
thirds of patients with CFS reported that they were dissatisfied
with the quality of their medical care and felt their clinicians
lacked communication skills and education regarding their
diagnosis .
Always Remember:
COUNSILNG IS VERY IMPORTANT!
The patient should have confidence that the physician will take a
rational, stepwise approach to the evaluation, and that the physician
will act as a guide in establishing therapeutic goals. These goals should
include:

• Accomplishing the activities of daily living

• Returning to work
• Maintaining interpersonal relationships
• Performing some form of daily exercise
• Brief regularly scheduled appointments can be used to monitor
progress in these areas and are preferred to having the patient
being seen on an "as needed" basis.
29
Systematic reviews of Dizziness and fatigue — often referred to as DFS have
determined effectiveness for only two treatments: cognitive behavioral
therapy (CBT) and graded exercise therapy.
• Antidepressants — A trial of antidepressant drugs should be offered to
patients whose illness has features of depression, regardless of whether
strict criteria for depression have been met. These agents should not be
used indiscriminately, but are safe enough to justify a time limited
therapeutic trial In one study of patients with medically unexplained
symptoms, including patients with chronic fatigue, full dose
antidepressant therapy was associated with 80 percent of the overall
response to a multidisciplinary treatment plan.
Patients should be advised that immediate response to antidepressant
therapy is not expected, and that treatment for several weeks would be
needed before their response could be assessed. Antidepressants may
themselves provoke or exacerbate fatigue, however, and should be
discontinued in patients who do not demonstrate symptom improvement
within a reasonable time frame (six to eight weeks).

Always Remember:
COUNSILNG IS VERY IMPORTANT! 30
• Cognitive behavioral therapy — Cognitive behavioral therapy is effective in
patients with CFS and may be useful in those with idiopathic chronic fatigue. This
approach typically involves a series of one-hour sessions designed to alter beliefs
and behaviors that might delay recovery. CBT components include explanation of
the model for chronic fatigue, challenging beliefs and awareness of fatigue and
reorienting these beliefs, achievement of physical activity goals and other
personal activity goals, and helping the patient attain control over symptoms.

• Graded exercise therapy — Graded exercise therapy (GET) is based on a

physiological model of deconditioning. Reported rates of observed improvement
with GET are approximately 55%, compared to 70% for CBT .

• Other measures — Other measures that may be useful include:

1. Provision of general sleep hygiene advice and discouraging over-sleeping
2. Provision of patient education brochures and other materials, discussion of
various aspects of chronic fatigue, and referral to support groups
3. Iron therapy in nonanemic patients with low serum ferritin may improve
symptoms of fatigue Always Remember:
COUNSILNG IS VERY IMPORTANT! 31
 Prognosis
Acute fatigue is often due to a self-limited or
reversible conditions, such as viral illnesses,
acute stressful situations, or medication side
effects.

Chronic fatigue has a more ominous prognosis;

between 50% to 70% of patients fail to improve
after a year of follow-up.
Always Remember:
COUNSILNG IS VERY IMPORTANT! 32