Back to Basics 2013 Fatigue Leonard Bloom MD Department of Family Medicine.

Back to Back to BasicsBasics20132013

FatigueFatigue

Leonard Bloom MD Leonard Bloom MD

Department of Family Department of Family MedicineMedicine

RationaleRationale

Fatigue is a common presenting Fatigue is a common presenting complaint in Primary Carecomplaint in Primary Care

20% of Family Medicine patients 20% of Family Medicine patients present with fatiguepresent with fatigue

Specific Disease not identified 35-Specific Disease not identified 35-54% of the time.54% of the time.

LMCC ObjectivesLMCC Objectives

1. Given a patient with fatigue, perform a 1. Given a patient with fatigue, perform a complete hx and P/E to establish the complete hx and P/E to establish the cause.cause.

2.Select and interpret investigations, 2.Select and interpret investigations, recognizing that tests may be of limited recognizing that tests may be of limited value. Lab values affect management in value. Lab values affect management in 5%.5%.

3. Develop a plan of management3. Develop a plan of management

Fatigue DefinitionFatigue Definition

Lack of energy, mental exhaustion, Lack of energy, mental exhaustion, poor muscle endurance, slow poor muscle endurance, slow recovery tiredness, weariness; recovery tiredness, weariness; described as exhaustiondescribed as exhaustion

Accompanied by a subjective Accompanied by a subjective sensation of weakness and a strong sensation of weakness and a strong desire to sleepdesire to sleep

Differentiate from sleepinessDifferentiate from sleepiness

Fatigue Fatigue Disturbs work performance, family Disturbs work performance, family

life and social relationships.life and social relationships.

Fatigue vs SleepinessFatigue vs Sleepiness

Sleepiness temporarily improved by Sleepiness temporarily improved by activity but fatigue is intensified.activity but fatigue is intensified.

Nap helps sleepiness.Nap helps sleepiness.

What conditions are associated What conditions are associated

with fatigue? with fatigue? (1) PHYSIOLOGIC(1) PHYSIOLOGIC

(a) imbalance in routines of exercise, (a) imbalance in routines of exercise,

sleep and diet.sleep and diet.

(b) post intense training and post (b) post intense training and post

reduced training after injury reduced training after injury

(c) post mental exertion(c) post mental exertion

Iatrogenic/Pharmacologic Iatrogenic/Pharmacologic CausesCauses

HypnoticsHypnotics Anti-hypertensivesAnti-hypertensives Anti-depressantsAnti-depressants Anti-histaminesAnti-histamines ““Recreational” Drugs: e.g. cannabisRecreational” Drugs: e.g. cannabis

Idiopathic CausesIdiopathic Causes

Idiopathic Chronic Fatigue Idiopathic Chronic Fatigue Chronic Fatigue SyndromeChronic Fatigue Syndrome FibromyalgiaFibromyalgia

Chronic Fatigue SyndromeChronic Fatigue Syndrome

Major Criteria forDx:Major Criteria forDx:

(1) Duration> 6 months(1) Duration> 6 months

(2) Does not resolve with rest(2) Does not resolve with rest

(3)reduces daily activity to <50%(3)reduces daily activity to <50%

(4) Other conditions excluded(4) Other conditions excluded

Chronic Fatigue Chronic Fatigue SyndromeSyndrome

Four of the following criteria necessary Four of the following criteria necessary for diagnosis:for diagnosis:

(1)Impairment of short-term memory(1)Impairment of short-term memory

(2)sore throat(2)sore throat

(3)tender cervical/axillary nodes(3)tender cervical/axillary nodes

(4)muscle pain(4)muscle pain

(5) joint pain(5) joint pain

Chronic Fatigue SyndromeChronic Fatigue Syndrome

(6)New headache(6)New headache

(7)Unrefreshing sleep(7)Unrefreshing sleep

(8)Post-exertion fatigue lasting>24 (8)Post-exertion fatigue lasting>24 hourshours

Other Diseases Associated Other Diseases Associated WithWith

Fatigue Fatigue PsychiatricPsychiatric Endocrine/ MetabolicEndocrine/ Metabolic Cardio-PulmonaryCardio-Pulmonary InfectionInfection Connective Tissue DisordersConnective Tissue Disorders Sleep DisordersSleep Disorders Neoplastic/HematologicNeoplastic/Hematologic

Mnemonic Mnemonic

P S V I N D I C A T EP S V I N D I C A T E

History History

Crucial to appropriate dxCrucial to appropriate dx Open-ended questions to appreciate Open-ended questions to appreciate

patient’s understanding of illnesspatient’s understanding of illness Establishing therapeutic alliance Establishing therapeutic alliance

whichwhich

is essential to dx and rx.is essential to dx and rx.

History History

What exactly is the patient’s What exactly is the patient’s experience?experience?

What is the quality of sleep?What is the quality of sleep?

Is there difficulty with sleep?Is there difficulty with sleep?

Are there emotional or disease Are there emotional or disease factors which interfere with sleep?factors which interfere with sleep?

Is there snoring or apnea?Is there snoring or apnea?

History History

DOES THE PATIENT FEEL RESTED IN DOES THE PATIENT FEEL RESTED IN AM AND MORE TIRED AS DAY GOES AM AND MORE TIRED AS DAY GOES ON; OR IS THE MORNING THE WORST ON; OR IS THE MORNING THE WORST TIME?TIME?

History History

Are there B symptoms: Fever, night Are there B symptoms: Fever, night sweats, weight loss, anorexiasweats, weight loss, anorexia

Are there symptoms related to Are there symptoms related to specific organ symptoms?specific organ symptoms?

Remember the IMPORTANCE OF Remember the IMPORTANCE OF NOCTURNAL SYMPTOMSNOCTURNAL SYMPTOMS

History History

Are there symptoms of DEPRESSION?Are there symptoms of DEPRESSION?

MSIGECAPSMSIGECAPS

Are there ongoing stresses?Are there ongoing stresses?

Physical ExaminationPhysical Examination

General AppearanceGeneral Appearance Vital Signs (Blood pressure, heart Vital Signs (Blood pressure, heart

rate and rhythm,?pallour)rate and rhythm,?pallour) ?Lymphadenopathy, ??Lymphadenopathy, ?

hepatomegaly, ??splenomegaly hepatomegaly, ??splenomegaly (neoplasm (neoplasm lymphoma,mononucleosis)lymphoma,mononucleosis)

?Rales (interstitial lung disease, CHF)?Rales (interstitial lung disease, CHF)

Physical ExaminationPhysical Examination

?New cardiac murmur (endocarditis)?New cardiac murmur (endocarditis) ?Thyroid enlargement ?Thyroid enlargement

((hypo/hyperthyroid)((hypo/hyperthyroid) ?Edema (Hepatic, renal, ?Edema (Hepatic, renal,

cardiac,nutritional disorders)cardiac,nutritional disorders)

Lab InvestigationsLab Investigations

CBCCBC ESRESR TSHTSH PREGNANCY TESTPREGNANCY TEST SCREENING CHEMISTRYSCREENING CHEMISTRY URINALYSISURINALYSIS OTHER TESTS ONLY WHEN OTHER TESTS ONLY WHEN

INDICATEDINDICATED

Treatment of FatigueTreatment of Fatigue

Importance of Physician’s Importance of Physician’s Commitment:Commitment:

Patients who believe that symptoms Patients who believe that symptoms

are related to modifiable factors are related to modifiable factors (workload, financial issues, (workload, financial issues, emotionally overburdened) more emotionally overburdened) more likely to improve than those who likely to improve than those who relate to organic factors e.g. virus.relate to organic factors e.g. virus.

Treatment of FatigueTreatment of Fatigue

Patients are actually seeking Patients are actually seeking recognition and support rather than recognition and support rather than investigation.investigation.

Treatment of FatigueTreatment of Fatigue

Treat underlying Disease including Treat underlying Disease including sleep disorderssleep disorders

Anti-depressants for depressionAnti-depressants for depression Regular physical activity: walking Regular physical activity: walking

and aerobics are the most benficial and aerobics are the most benficial interventionsinterventions

Short naps Short naps

Treatment of FatigueTreatment of Fatigue

Caffeine, modafanil for sleep disorders; Caffeine, modafanil for sleep disorders; e.g related to shift worke.g related to shift work

Sustaining inter-personal relationships, Sustaining inter-personal relationships, returning to work / time off workreturning to work / time off work

Yoga, group therapy, stress Yoga, group therapy, stress management decrease fatigue in management decrease fatigue in patients with cancerpatients with cancer

Adequate sleep: ?amitriptyline ?Adequate sleep: ?amitriptyline ?trazodonetrazodone

Treatment of FatigueTreatment of Fatigue

Schedule regular visits to validate Schedule regular visits to validate distress and not minimize itdistress and not minimize it

CBT might be useful in treating CBT might be useful in treating chronic fatigue.chronic fatigue.

51 yo woman with fatigue51 yo woman with fatigue

HPI: This is a 51 yo woman with a c/o HPI: This is a 51 yo woman with a c/o severe fatigue, pain and swelling in severe fatigue, pain and swelling in her joints and muscles. Pain in the her joints and muscles. Pain in the lateral thighs causes a giving way lateral thighs causes a giving way feeling. There is a concern about feeling. There is a concern about pain and swelling in her knees, pain and swelling in her knees, legs,arms, feet and hands. Back and legs,arms, feet and hands. Back and neck discomfort. Poor sleep.neck discomfort. Poor sleep.

Past HistoryPast History

Carcinoma of the bowel with Carcinoma of the bowel with resection and no adjuvant Rx resection and no adjuvant Rx required.required.

HypothyroidismHypothyroidism PerimenopausalPerimenopausal

MedicationsMedications

Synthroid 0.125 mgs.Synthroid 0.125 mgs.

Social HxSocial Hx

Works in a school with children with Works in a school with children with behavioural problems and learning behavioural problems and learning disabilitiesdisabilities

Very committed to job but Very committed to job but emotionally draining.emotionally draining.

Stresses in personal family lifeStresses in personal family life

What is your approach?What is your approach?

What questions do you wish to ask?What questions do you wish to ask? What P/E would you do?What P/E would you do? What testing/imaging?What testing/imaging? What therapy is appropriate?What therapy is appropriate?

Fatigue – In SummaryFatigue – In Summary

The history is critical.The history is critical. The diagnosis is often not obvious.The diagnosis is often not obvious. A screening physical exam and basic A screening physical exam and basic

lab work will compliment the history.lab work will compliment the history. Therapeutic relationship is essential Therapeutic relationship is essential

to an accurate dx. and improvementto an accurate dx. and improvement

Questions?