essential for every doctor

1. DR. IMRUL HASAN
MD RESIDENT (GASTROENTEROLOGY)
BIRDEM GENERAL HOSPITAL

2. APPROACH TO FATIGUE

3. INTRODUCTION
• Fatigue is defined as subjective complaint of tiredness and diminished
energy level to the point of interfering of normal or usual activity.
• It is very common and non specific, so identifying significant
underlying disease is difficult.

4. TYPES
According to duration
• Recent (less then one month)
• Prolonged (more then one month)
• Chronic (over six month)

5. CAUSES
Non-organic
• Psychological
• Fibromyalgia.
• Chronic fatigue syndrome.
Medications
• Beta-blockers.
• Sedatives.
• Corticosteroids.
• Chemotherapeutic agents.
Malignancy
Respiratory
• Obstructive sleep apnoea.
• COPD
 Cardiac
• Congestive cardiac failure.
• Bradyarrythmia

6. Cont.
 Haematological
• Anaemia.
Endocrine
• Hypothyroidism.
• Hypercalcaemia.
• Diabetes mellitus.
• Adrenal insufficiency.
• Hypopituitarism
Infection
• Infectious mononucleosis.
• Tuberculosis.
• HIV.
• Infective endocarditis.
Chronic inflammatory conditions
• Rheumatoid arthritis.
• Inflammatory bowel disease.
• SLE

8. STEP BY STEP ASSESMENT
1.Likely drug culprit?
Review all medications. Stop or replace suspect medications and review
symptoms after an appropriate interval.

9. 2. Definite cause identified on examination or screening investigation?
If any of the abnormalities listed below are detected, reassess fatigue
after appropriate evaluation and treatment.
• Anemia: This may cause fatigue but is also a common feature of
chronic disease. Assessment of anemia is necessary in any patient
with low Hb level.
• Renal failure: Uremia is a cause of fatigue. If there is new or
worsening renal impairment, need assessment of renal failure.
• Diabetes mellitus: Evaluate for diabetes if patient has suggestive
symptom or raised fasting or random blood glucose level. Poor
glycemic control in known diabetes may cause fatigue. Review blood
glucose diary and HbA1c to determine whether control is adequate and
if not,reassess the fatigue after correction. Repeated episode of
hypoglycemia may also cause fatigue and should be address.

10. Cont
• Hypercalcaemia: Fatigue and other symptoms, e.g. abdominal pain,
vomiting, constipation, polyuria, confusion and anorexia, may occur if
corrected serum calcium is >3.0 mmol/L. Hypercalcaemia may reflect
serious underlying disease, e g. bony metastases, squamous cell lung
cancer and multiple myeloma. Firstly, check a parathyroid hormone
(PTH) level: • an ↑ or →PTH suggests primary hyperparathyroidism.
Refer to Endocrinology • if ↓PTH, examine the breasts and prostate,
perform a CXR, a radioisotope bone scan and myeloma ‘screen’,
review drugs (especially calcium or vitamin D supplements). If no
cause is identified, consider a CT scan of the chest, abdomen and
pelvis to look for underlying malignancy.

11. Cont.
• Hypothyroidism: Ask about symptoms of cold intolerance,
constipation and weight gain, and look for hypothyroid facies, dry
skin, brittle hair and nails, myxoedema and goitre. In patients with
known hypothyroidism, consider whether thyroxine replacement is
adequate and ask about compliance. ↑TSH and ↓T4 confirms primary
hypothyroidism. Low TSH with low T4 – this may indicate secondary
hypothyroidism so perform a full pituitary hormone profile.
• Pregnancy: Consider in any woman of child-bearing age and, if
necessary, perform a pregnancy test

12. 3. Fever, night sweats or ↑inflammatory
markers?
• Fatigue is a common, and often predominant symptom in patients with
systemic inflammatory or malignant disease, e.g. lymphoma,
endocarditis, myeloma, tuberculosis. If there is a history of fever or
night sweats or an ↑ESR/CRP,than review as per pyrexia of unknown
origin.

13. 4.Other indicator of organic disease
• Abnormalities on FBC or blood film: High or low cell counts, abnormal cells,
e.g. blasts, or morphological abnormalities, e.g. target cells may indicate
important haematological or systemic disease. Seek haematological advice
for abnormality.
• Lymphadenopathy: Enlarged lymph nodes may occur with malignancy
(lymphoma, leukaemia or secondary deposits) or in reaction to
infection/inflammation. The most important conditions to consider are HIV,
tuberculosis (TB), infectious mononucleosis and malignancy • Search for a
local source of infection/ inflammation if swelling is localized to one lymph
node group. • Suspect haematological malignancy if there is generalized
painless lymphadenopathy. • Consider lymph node biopsy if the cause is
not apparent or suspected malignancy

14. Cont.
• Evidence of cardiorespiratory dysfunction: Look for features of
cardiac failure (↑JVP, peripheral oedema, pulmonary congestion) or a
new murmur; if present, arrange an ECG and echocardiogram. Check
SpO2 at rest ± on exertion; if low, perform an ABG on room air and
look for an underlying cause. Ask about smoking history and consider
CXR/pulmonary function tests.
• Features of chronic liver disease or abnormal LFTs: Look for stigmata
of chronic liver disease.If LFTs are abnormal, enquire about alcohol
intake and discontinue hepatotoxic drugs; if the abnormality persists,
consider a liver screen

15. Cont.
• Features of adrenal insufficiency: Look for pigmentation of sun-
exposed areas, palmar creases and mucosal membranes; vitiligo/other
autoimmune conditions; postural hypotension and ↓Na+ /↑K+ .
Confirm with a short ACTH (Synacthen) stimulation test.

16. 5.Specific infection risk?
• Consider HIV if the patient: has had unprotected sex, h/o blood
transfusion, resident in an HIV endemic area, engaged in high-risk
sexual activity, an IV drug user.
• Consider a CXR ± Mantoux test if the patient: had previous TB or
resident in a TB endemic area, recent exposure to TB patient,
immunosuppression.
• Consider Lyme serology if the patient has: h/o tick bite, travelled to an
endemic area.

17. 6. Low mood, anhedonia?
• Suspect depression if the patient has lost enjoyment or interest in life
Look for blunted affect, psychomotor retardation and biological
symptoms, e.g. loss of libido. Consider psychiatric referral or a trial of
antidepressants.

18. 7. Explore psychosocial factors and impact on
lifestyle. Consider obesity, physical
deconditioning, chronic fatigue syndrome
• If the patient has a BMI >30 or lacks physical fitness, encourage
appropriate lifestyle changes and reassess

19. CHRONIC FATIGUE SYNDROME
• Chronic fatigue syndrome is a diagnosis of exclusion with specific criteria.
• Diagnostic criteria:
Fatigue for ≥4 months with all of the following:
• persistent and/or recurrent symptoms • unexplained by other conditions •
a substantial reduction in activity level • feeling worse after physical
activity and one or more of the following:
• insomnia• muscle and/or joint pain without inflammation • headaches •
painful lymph nodes that are not enlarged • sore throat or general malaise
or flu-like symptoms • cognitive dysfunction• physical or mental exertion
that makes symptoms worse • dizziness and/or nausea • palpitation, without
heart disease.

20. REFERENCE
• MACLEOD’S CLINICAL DIAGNOSIS ( 2ND EDITION)
Auther: Alan G Japp & Colin Robbertson