Fatigue resident survival guide

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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.

Common Causes

  • 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 [1]
 
Consider differential diagnosis:
Chronic obstructive pulmonary disease [2]
Sleep apnea [3]
 
Consider differential diagnosis:
Hypothyroidism [4]
Hyperthyroidism [5]
❑ Inflammatory bowel disease [6]
Chronic renal disease [7]
Chronic hepatic disease [8]
Adrenal insufficiency [9]
Hyponatremia [10]
Hypercalcemia [11]
 
Consider differential diagnosis:
Anemia [11]
Occult malignancy [12]
 
 
 
Consider differential diagnosis:
Depression [20]
Anxiety disorder [21]
Somatization disorder [22]

Treatment

.

 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fatigue due to heart failure[23][24][25][26] :
❑Diuretics
❑Vasodilator Therapy
❑Inotropic Therapy
❑Vasopressor Support
❑ACE Inhibition
❑Beta Blockers
❑Aldosterone Antagonism
❑Morphine
Fatigue due to stable angina[27]:
❑Antiplatelet agents
❑Antianginal agents
❑ACEI/RAAS Blockers
 
Ftigue due to Chronic obstructive pulmonary disease[28][29][30].:
❑Beta Adrenergic Receptor Agonists
❑Long Acting Beta-2 Adrenergic Receptor Agonist
❑Anticholinergics
❑Phosphodiesterase Inhibitor
❑Steroid
❑Antibiotics
❑Mucolytic
Fatigue due to sleep apnea:[31].[32][33][34][35]
❑Weight loss
❑Continuous positive airway pressure
❑Oral appliances
❑Modafinil 200-400 mg per day
❑Acetazolamide
 
Fatigue due to hypothyroidism:.[36][37]
[38]:
❑Synthetic T4(Levothyroxin)
Fatigue due to hyperthyroidism:[39]
❑Beta blockers
❑Methimazole
❑Propylthiouracil
Fatigue due to Chronic Renal Failure:[40]
❑Blood pressure management
❑Kidney Transplant
 
Fatigue due to anemia:[41][42] [43]
❑Blood transfusion,
❑Iron transfusion
❑Folate therapy
❑Vit B12
 
Fatigue due to Mononucleosis[44]
[45][46][47][48][49][50]
NSAID
❑Intravenous corticostreoid
Acyclovir
❑Opioid analgesics
Fatigue due to Viral Hepatitis.[51][52][53][54]:
❑Entecavir
❑Tenofovir
❑Interferon-α 2b
❑PegIFNα
❑Telbivudine
❑Adefovir
❑Lamivudine
Fatigue due to Endocarditis[55]:
❑Empiric antibiotics
❑Antithrombotic therapy
 
Fatigue due to Fibromyalgia:[56]; [57][58]
❑Amitriptiline
❑Cyclobenzaprine
❑Dulexitine
❑Minlacipran
❑Pregabalin
Fatigue due to Polymyalgia:[59][59]
❑Glucocorticosteroids
Fatigue due to Rheumatoid arthritis:[60][61]
[62]

❑Leflunomide
❑Sulfasalazine
❑Hydroxycloroquine
❑Rituximab
❑Tocolizumab
❑Azathioprim
❑Cyclosporine
❑Anakirna
❑Abatacept
❑Baricitinib
❑DMARDS
Fatigue due to Sjögren's syndrome[63][64][65]
[66]

❑Pilocarpine
❑Cevimeline
❑Methotroxate
 
Fatigue due to Mood disorders:[67]
❑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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