Fatiguepres2

Fatigue, Malaise,Insomnia: 

Fatigue, Malaise, Insomnia Cynthia Augereau Melissa Morrison

Fatigue: 

Fatigue Fatigue is a feeling of weariness, tiredness or lack of energy. Usually associated with feelings of sleepiness, irritability, boredom and decreased efficiency (Uphold & Graham). Can be a normal response to physical exertion, emotional stress, boredom, or lack of sleep Can also be do to psychological or physical disorders COMMON COMPLAINT! http://www.nlm.nih.gov/medlineplus/ency/article/003088.htm

Some common causes of fatigue: 

Some common causes of fatigue Anemia Sleep disorders: insomnia, Sleep apnea, narcolepsy Chronic pain Hypothyroidism Drug or alcohol abuse Depression Allergies

Malaise: 

Malaise Malaise is a generalized feeling of discomfort, illness, or lack of well- being accompanied by a feeling of exhaustion and/or lack of energy Nonspecific symptom that usually coexists with fatigue Can occur with almost any sigificant infections, metabolic, or systemic disorder Onset may be slow or rapid depending on nature of the disease http://www.nlm.nih.gov/medlineplus/ency/article/003089.htm

Insomnia: 

Insomnia Insomnia- sleep that is unrefreshing or nonrestorative, as well as a persistent difficulty in falling or staying asleep (Uphold & Graham). Acute- lasts a few days, usually due to stress, acute illness, jet lag, noise, light, and temperature changes Chronic- Lasts more than 4 weeks with multifactorial causes

Some causes of Insomnia: 

Some causes of Insomnia Stress Psych d/o like depression or anxiety Etoh, caffeine, nicotine Prescription drugs like decongestants, beta blockers, thyroid hormones, SSRIs Sleep apnea Jet lag or shift work Many medical conditions including GI, cardiac, respiratory, CNS, musculoskeletal conditions, endocrine, and pain

Case Study: 

Case Study 28 year old graduate student c/o extreme fatigue during the day and inability to fall and stay asleep, progressively worse over the last 3 months. 10 lb weight gain in last 6 months Does not smoke or use recreational drugs, drinks a glass of wine or two from time to time Drinks one cup of coffee every morning, avoids caffeine after 5pm Admits to poor diet habits and lack of exercise due to increased stress from school and full-time work

HPI: 

HPI C/O feeling tired since starting graduate school 8 months ago C/O more migraines than usual during last 3 weeks Usually sleeps 4-5 hrs per night but still feels tired in the morning Takes Benadryl 25mg nightly to help with sleep, complains that it makes her feel groggy in the morning. Pt can’t sleep if she doesn’t take Benadryl. C/O difficulty concentrating at times, feels “run-down” Denies fever, dizziness, SOB, muscle weakness/ spasms or pain other than H/A

PMH & Medications: 

PMH & Medications Asthma as a child, now resolved Migraine headaches – 1-2 per month.Takes Imitrex prn Chronic sinusitis from environmental allergies- Takes Rhinocort during flare-ups Yasmin for BCP Takes an MVI every day NKDA

Physical Exam: 

Physical Exam VS: BP 110/70, P: 72(reg), RR: 18, Temp: 97.7F Height: 5’8” 190 lbs LMP: one week ago, normal General: Appropriate color, tired, ill appearing female in NAD HEENT: Negative, except for dark circles under eyes, no lymphadenopathy CV: RRR S1, S2, no murmurs, rubs, or gallops Lungs: CTA no adventitious BS GI: BS present all 4 quads, abd soft, no organomegaly GU/Genitals: deferred

Differential Diagnosis: 

Differential Diagnosis Hypothyroidism Depression Sleep apnea Infectious Mononucleosis Anemia Chronic fatigue syndrome Insomnia

Hypothyroidism : 

Hypothyroidism Fatigue, weight gain, cold intolerance, heavy menses, constipation, dry skin, depression, hypersomnia, coarse hair, hair loss, forgetfulness Check TSH, T3, T4 All levels WNL for this patient If hypothyroid, TSH levels high, T3, T4 levels low Treat hypothyroidism with replacement thyroid hormones (levothyroxine/synthroid)

Depression: 

Depression Diagnostic criteria for major depression: 5 of the following: one of which must be #1 or #2 1: Depressed mood 2: Loss of interest of pleasure in most activities 3: Significant weight loss/gain or change in appetite 4: Insomnia or hypersomnia 5: Psychomotor agitation or retardation 6: Loss of energy or fatigue 7: Feelings of worthlessness or excessive guilt 8: Diminished ability to think or concentrate 9: Recurrent thoughts of suicide or death 10: Symptoms that cause disturbance in social or occupational areas of functioning

Depression: 

Depression This patient has 4 of the criteria, but #1 or #2 not included, pt denies feeling depressed; screening done to r/o depression: Beck Depression Inventory:21 item self report Based on this inventory pt ruled out for depression If diagnosis of depression were made can treat with: SSRI, TCA, psychotherapy, etc Two thirds of fatigue cases are related to depression according to Uphold & Graham

Sleep Apnea: 

Sleep Apnea Patient’s partner has not noticed any periods of apnea or excessive snoring while patient is sleeping If sleep apnea is suspected, a sleep study can be done If sleep apnea is diagnosed, CPAP can be used as treatment Weight loss can help decrease incidence of sleep apnea

Infectious Mononucleosis: 

Infectious Mononucleosis Fatigue, Headache, fever, exudative pharyngitis, lymphadenopathy (esp in posterior cervical chain), enlarged spleen, petechial rash Illness can result in fatigue for 6-12 months Atypical lymphocytosis and abnormal LFTs CBC and LFTs were normal in this patient Heterophil antibody present in 90% of mono in adults- negative in this patient If patients symptoms were found to be caused by mono, only symptomatic treatment would be needed

Anemia: 

Anemia Pallor, fatigue, dyspnea, headache, poor concentration, anorexia, often asymptomatic CBC will show low Hgb, Hct WNL for this patient B12, ferritin, and folate levels to determine iron deficiency,or megaloblastic anemias (B12 or folate deficiencies) also WNL for this patient Replete deficiencies if found to reverse anemia, dietary counseling

Chronic Fatigue Syndrome: 

Chronic Fatigue Syndrome International Consensus Definition of Chronic fatigue syndrome: Chronic or relapsing, unexplained, severe fatigue for 6 or more months that is not the result of ongoing exertion, is not substantially alleviated by rest, and results in reduction in previous levels of occupational, social or personal activities AND Four or more of the following: Impaired memory or concentration Sore throat Muscle pain New headaches Multijoint pain Unrefreshing sleep Postexertional malaise

Chronic Fatigue Syndrome: 

Chronic Fatigue Syndrome Thorough history is needed for diagnosis  In addition to labs already done, UA, Sed rate, and BMP should be done to r/o other possible etiologies (all are normal on this patient) If diffuse adenopathy present, HIV testing should be done Diagnosis is based on clinical findings and exclusion of other diagnoses This patient does not have enough of diagnostic criteria to make this diagnosis

Treatment of Chronic Fatigue Syndrome: 

Treatment of Chronic Fatigue Syndrome Treat underlying cause of fatigue; symptomatic care like pain meds and strategies to normalize sleep patterns Treatment is tailored for each patient; focus is on rehabilitation rather than cure (chronic condition) Reassure patients that CFS is not lifethreatening Targeted exercise program, a balanced diet, and good sleep hygiene may help to improve symptoms Low-dose TCAs and SSRIs may also help

Insomnia: 

Insomnia The diagnosis of insomnia is also one of exclusion Diagnosis of chronic insomnia requires: -difficulty initiating of maintaining sleep -presence of nonrestorative sleep -disturbance not due to another sleep or mental disorder Diagnosis requires thorough history taking

Diagnosis: 

Diagnosis Based on clinical findings and exclusion of other differentials, chronic insomnia is the diagnosis made for this patient!

Treatment of Chronic Insomnia: 

Treatment of Chronic Insomnia Medications can be used for short term treatment (3-4 weeks at a time) Benzodiazepines (Halcion, Restoril), or Nonbenzodiazepines (Ambien, Lunesta, Sonata) can be used Prescribe lowest effective dose Instruct patient to only take every other or every third night

Patient education: 

Patient education When no underlying cause can be found for insomnia, education and behavioral treatments should be instituted Have patient keep sleep diary for 2 weeks including: Hours spent in bed Hours spent sleeping Number of awakenings Timing and quantity of meals Use of alcohol or medications before bed Time of awakening Follow up in two weeks to assess sleep patterns and problems so a treatment plan can be formulated

Sleep hygiene education: 

Sleep hygiene education Avoid alcohol in the late evening. Although it can help to facilitate sleep onset, it will cause early awakening Avoid stimulants such as nicotine and caffeine in the evenings Avoid heavy meals before bed, have a light snack instead Avoid exercise within 4 hours of bedtime Wake up at the same time each day Make sure bedroom is free of environmental sleep disturbances like light, noise, and excessive temperatures

Stimulus-control therapy: 

Stimulus-control therapy Helps to create a new association between the bed/bedroom and the onset of sleep Go to bed only when sleepy Use bed only for sleeping (sex is only exception) Do not read, eat, work, or watch TV in bed If unable to fall asleep after 15-20 minutes, get up and read a book under dim light in another room. Do not watch TV because the light has an arousing effect Get out of bed at the same time each day regardless of total hours of sleep Minimize daytime napping, if absolutely necessary take a brief nap in the early afternoon

Follow-up & Referral: 

Follow-up & Referral After initial 2 week follow up to evaluate sleep diary, have patient continue to keep sleep diary, then follow up again in 1 month to evaluate effectiveness of education and interventions prescribed Suggest alternative approach if the initial one did not work If no improvement, and other causes still ruled out, can evaluate for sleep study

References: 

References Fatigue, (n.d). Retrieved March 12, 2007 from http://www.nlm.nih.gov/medlineplus/ency/article/003088.htm Insomnia. (n.d). Retrieved March 20, 2007 from http://en.wikipedia.org/wiki/Insomnia Malaise. (n.d). Retrieved March 20, 2007 from http://www.nlm.nih.gov/medlineplus/ency/article/003089.htm Uphold, C.R., & Graham, M.V. (2003). Clinical guidelines in family practice (4th ed.). Gainesville, Fl: Barmarrae Books Inc.