Fatigue resident survival guide

Fatigue Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]Mounika Lakhmalla, MBBS[3]Ramyar Ghandriz MD[4]

Synonyms and keywords:Approach to weakness, Approach to tiredness, Approach to lethargy, Approach to debility

Overview

Fatigue is a common nonspecific symptom due to a wide range of etiologies. Patients often use this term to describe a range of issues such as difficulty initiating activity, decreased capacity to maintain activity, trouble with concentration, memory, and emotional stability; or sleepiness or an uncontrollable need to sleep. The term fatigue can sometimes be used synonymously with tiredness. Fatigue can present alone as a primary symptom or in association with other localizing symptoms.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Active Malignancy

Common Causes

• Infection
• Diabetes
• Hypercalcemia
• Anemia
• Rheumatologic diseases
  • Fibromyalgia
  • Rheumatoid Arthritis
  • Polymyalgia Rheumatica
  • Systemic Lupus Erythymatosus
  • Sjögren's syndrome
• Inflammatory Bowel Disease
• Neurologic injury
• Endocrine Causes:
  • Adrenal insufficiency
  • Thyroid insufficiency
  • Hyperthyroidism
  • Electrolyte abnormalities
• Chronic Hepatic diseases
• Renal insufficiency
• Cardiopulmonary diseases
  • Congestive heart failure
  • Chronic obstructive pulmonary disease
  • Peripheral vascular disease
  • Atypical angina
  • Obstructive sleep apnea.
• Myopathy
• Medications & Substance abuse
  • Sedative-hypnotics
  • Analgesics
  • Antihypertensives
  • Antidepressants
  • Muscle relaxants
  • Opioids
  • Antibiotics
  • Alcohol
  • Marijuana
  • Cocaine/other stimulants
  • Anticancer agents (like cisplatin and Etoposide)
• Psychological Causes:
  • Depression
  • Anxiety
  • Somatization disorder
  • Dysthymic disorder
  • chronic fatigue syndrome

• Multiple sclerosis
• After malignancy treatment, patients can experience different patterns of fatigue from chemotherapy, radiation treatment, or surgery.

Diagnosis

The approach to the diagnosis of fatigue is based on a step-wise testing strategy. Below is an algorithm summarizing the identification and laboratory diagnosis of fatigue.

• Diagnostic evaluation of fatigue when it presents as a predominant symptom includes a detailed history and physical examination, basic laboratory studies, and updated cancer screening interventions.
• Additional diagnostic testing depends on associated localized findings.
• Extensive laboratory studies without a suggestive history or physical exam findings is of limited diagnostic utility while evaluating chronic fatigue.

Seek proper history, ask patients to describe in their own words, what do they mean by fatigue? This will help distinguish fatigue from ❑ somnolence ❑ muscle weakness The history should also determine the characteristics, severity, and temporal pattern of fatigue: ❑ Onset – Abrupt or gradual, relationship to illness or life event ❑ Course – Stable, improving, or worsening ❑ Duration and daily pattern ❑ Factors that alleviate or exacerbate it ❑ Impact on daily life – Ability to work, socialize, participate in family activities ❑ Accommodations that the patient/family has had to make to deal with symptom

Characterize the cardiac symptoms: ❑ Dyspnea on exertion ❑ Orthopnea ❑ Leg swelling

Characterize the pulmonary symptoms: ❑ Dyspnea ❑ Chronic cough ❑ Sputum production ❑ Snoring ❑ Interrupted breathing during sleep

Characterize the endocrinologic / metabolic symptoms: ❑ Cold intolerance ❑ Weight gain ❑ Constipation ❑ Dry skin ❑ Heat intolerance ❑ Weight loss ❑ Diarrhea ❑ Moist skin ❑ Nausea/vomiting ❑ Mental status changes ❑ Decreased urine ❑ Abdominal distention ❑ Gastrointestinal bleeding ❑ Salt craving ❑ Gastrointestinal complaints ❑ Malaise ❑ Cognitive dysfunction ❑ Anorexia ❑ Polydipsia/polyuria

Characterize the hematologic / neoplastic symptoms: ❑ Dizziness ❑ Weakness ❑ Palpitations ❑ Dyspnea ❑ Weight loss

Characterize the Infectious diseases symptoms: ❑ Fever/chills ❑ Sore throat ❑ Tender lymph nodes ❑ Nausea/vomiting ❑ Abdominal discomfort ❑ Weight loss ❑ Night sweats ❑ Myalgias

Characterize the rheumatologic symptoms: ❑ Chronic diffuse muscle pain ❑ Aching/morning stiffness of shoulders, neck, and hips

Characterize the psychological symptoms: ❑ Sad mood ❑ Anhedonia ❑ Altered sleep ❑ Cognitive dysfunction ❑ Generalized nervousness ❑ Panic attacks ❑ Phobias ❑ Multiple chronic constitutional and localized complaints

Examine the patient: ❑ Elevated jugular venous distension ❑ Peripheral edema ❑ S3 gallop ❑ Inspiratory rales

Examine the patient: ❑ Evidence of hyperinflation ❑ Wheezing ❑ Rales ❑ Obesity ❑ Hypertension

Examine the patient: ❑ Bradycardia ❑ Goiter ❑ Slow deep tendon reflex relaxation phase ❑ Tachycardia ❑ Ophthalmopathy ❑ Hypertension ❑ Peripheral edema ❑ Jaundice ❑ Palmar erythema ❑ Gynecomastia ❑ Splenomegaly ❑ Evidence of ascites ❑ Hypotension ❑ Hyperpigmentation ❑ Vitiligo

Examine the patient: ❑ Tachycardia ❑ Pallor

Examine the patient: ❑ Fever ❑ Exudate pharyngitis ❑ Tender cervical adenopathy ❑ Jaundice ❑ Tender hepatomegaly ❑ New (regurgitant) murmur ❑ Cough ❑ Chest pain ❑ Dyspnea ❑ Hemoptysis

Examine the patient: ❑ Multiple "tender points" on palpation ❑ Decreased range of motion of shoulders, neck, and hips

Examine the patient: ❑ Tachycardia ❑ Muscle tension

Diagnostic work-up: ❑ Chest radiograph ❑ Echocardiogram

Diagnostic work-up: ❑ Chest radiograph ❑ Sleep study

Diagnostic work-up: ❑ Thyroid function tests ❑ Renal function tests/ serum electrolytes ❑ Hepatic function tests ❑ Morning cortisol/ACTH, ACTH stimulation test ❑Serum sodium level ❑Serum calcium level

Diagnostic work-up: ❑ Complete blood count

Diagnostic work-up: ❑ Complete blood/differential count ❑ Monospot ❑ Hepatic function tests ❑ Viral hepatitis serologies ❑ HIV serology ❑ Blood cultures ❑ Echocardiogram ❑ PPD/gamma-interferon assay ❑ Chest radiograph

Diagnostic work-up: ❑ Erythrocyte sedimentation rate

Diagnostic work-up: ❑ Screening tests (eg, PHQ-2, PHQ-9, GAD-7, SSS-8

Consider differential diagnosis: ❑ Congective heart failure ❑ Atypical angina

Consider differential diagnosis: ❑ Chronic obstructive pulmonary disease ❑ Sleep apnea

Consider differential diagnosis: ❑ Hypothyroidism ❑ Hyperthyroidism ❑ Inflammatory bowel disease ❑ Chronic renal disease ❑ Chronic hepatic disease ❑ Adrenal insufficiency ❑ Hyponatremia ❑ Hypercalcemia

Consider differential diagnosis: ❑ Anemia ❑ Occult malignancy

Consider differential diagnosis: ❑ Mononucleosis syndrome ❑ Viral hepatitis ❑ HIV infection ❑ Subacute bacterial endocarditis ❑ Tuberculosis

Consider differential diagnosis: ❑ Fibromyalgia ❑ Polymyalgia rheumatica ❑ Rheumatoid arthritis ❑ Sjogren syndrome ❑ Systemic lupus erythematosus

Consider differential diagnosis: ❑ Depression ❑ Anxiety disorder ❑ Somatization disorder

Treatment

.

Treat the underlying causes

Fatigue due to heart failure : ❑Diuretics ❑Vasodilator Therapy ❑Inotropic Therapy ❑Vasopressor Support ❑ACE Inhibition ❑Beta Blockers ❑Aldosterone Antagonism ❑Morphine Fatigue due to stable angina: ❑Antiplatelet agents ❑Antianginal agents ❑ACEI/RAAS Blockers

Ftigue due to Chronic obstructive pulmonary disease.: ❑Beta Adrenergic Receptor Agonists ❑Long Acting Beta-2 Adrenergic Receptor Agonist ❑Anticholinergics ❑Phosphodiesterase Inhibitor ❑Steroid ❑Antibiotics ❑Mucolytic Fatigue due to sleep apnea:. ❑Weight loss ❑Continuous positive airway pressure ❑Oral appliances ❑Modafinil 200-400 mg per day ❑Acetazolamide

Fatigue due to hypothyroidism:. : ❑Synthetic T4(Levothyroxin) Fatigue due to hyperthyroidism: ❑Beta blockers ❑Methimazole ❑Propylthiouracil Fatigue due to Chronic Renal Failure: ❑Blood pressure management ❑Kidney Transplant

Fatigue due to anemia: ❑Blood transfusion, ❑Iron transfusion ❑Folate therapy ❑Vit B12

Fatigue due to Mononucleosis ❑NSAID ❑Intravenous corticostreoid ❑Acyclovir ❑Opioid analgesics Fatigue due to Viral Hepatitis.: ❑Entecavir ❑Tenofovir ❑Interferon-α 2b ❑PegIFNα ❑Telbivudine ❑Adefovir ❑Lamivudine Fatigue due to Endocarditis: ❑Empiric antibiotics ❑Antithrombotic therapy

Fatigue due to Fibromyalgia:; more recent studies make this doubtful. ❑Amitriptiline ❑Cyclobenzaprine ❑Dulexitine ❑Minlacipran ❑Pregabalin Fatigue due to Polymyalgia: ❑Glucocorticosteroids Fatigue due to Rheumatoid arthritis: ❑Leflunomide ❑Sulfasalazine ❑Hydroxycloroquine ❑Rituximab ❑Tocolizumab ❑Azathioprim ❑Cyclosporine ❑Anakirna ❑Abatacept ❑Baricitinib ❑DMARDS Fatigue due to Sjögren's syndrome ❑Pilocarpine ❑Cevimeline ❑Methotroxate

Fatigue due to Mood disorders: ❑CBT ❑Anti depresant therapy ❑Anxiolytic therapy

Do's

• Though most of the conditions presenting with fatigue have the luxury of time for appropriate evaluation & treatment, a few may require immediate diagnosis & treatment to prevent death or serious sequelae.
• In case of Cardiovascular emergencies: In symptomatic Heart failure secondary to atrial fibrillation, hemodynamically unstable patients require urgent direct-current cardioversion.
• Endocrine disorders: Diabetic ketoacidosis or nonketotic hyperglycemic states require urgent correction of blood sugar levels, acidosis, electrolyte & Fluid imbalances.
• Infectious disease
  • Untreated tuberculosis: respiratory failure and systemic spread of disease in immunocompromised individuals.
  • HIV, if not diagnosed or treated appropriately with antiretroviral drugs, may result in overt AIDS and eventually death.
  • Coronavirus disease 2019 (COVID-19)
    • Patients may develop severe viral pneumonia leading to acute respiratory distress syndrome that is potentially fatal.
    • Suspected COVID-19 infection should be isolated from others, along with contact and droplet precautions, airborne precautions if performing aerosol-generating procedures.

Don'ts

• Extensive laboratory work-up is rarely helpful in the absence of suggestive signs and symptoms.
• Mannitol is contraindicated in fatigue treatment.

References

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