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

2. Rationale Rationale Fatigue is a common presenting complaint in Primary Care Fatigue is a common presenting complaint in Primary Care 20% of Family Medicine patients present with fatigue 20% of Family Medicine patients present with fatigue Specific Disease not identified 35-54% of the time. Specific Disease not identified 35-54% of the time.

3. LMCC Objectives LMCC Objectives 1. Given a patient with fatigue, perform a complete hx and P/E to establish the cause. 1. Given a patient with fatigue, perform a complete hx and P/E to establish the cause. 2.Select and interpret investigations, recognizing that tests may be of limited value. Lab values affect management in 5%. 2.Select and interpret investigations, recognizing that tests may be of limited value. Lab values affect management in 5%. 3. Develop a plan of management 3. Develop a plan of management

4. Fatigue Definition Fatigue Definition Lack of energy, mental exhaustion, poor muscle endurance, slow recovery tiredness, weariness; described as exhaustion Lack of energy, mental exhaustion, poor muscle endurance, slow recovery tiredness, weariness; described as exhaustion Accompanied by a subjective sensation of weakness and a strong desire to sleep Accompanied by a subjective sensation of weakness and a strong desire to sleep Differentiate from sleepiness Differentiate from sleepiness

5. Fatigue Disturbs work performance, family life and social relationships. Disturbs work performance, family life and social relationships.

6. Fatigue vs Sleepiness Fatigue vs Sleepiness Sleepiness temporarily improved by activity but fatigue is intensified. Sleepiness temporarily improved by activity but fatigue is intensified. Nap helps sleepiness. Nap helps sleepiness.

7. What conditions are associated 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

9. Iatrogenic/Pharmacologic Causes Iatrogenic/Pharmacologic Causes Hypnotics Hypnotics Anti-hypertensives Anti-hypertensives Anti-depressants Anti-depressants Anti-histamines Anti-histamines “Recreational” Drugs: e.g. cannabis “Recreational” Drugs: e.g. cannabis

10. Idiopathic Causes Idiopathic Causes Idiopathic Chronic Fatigue Idiopathic Chronic Fatigue Chronic Fatigue Syndrome Chronic Fatigue Syndrome Fibromyalgia Fibromyalgia

11. Chronic Fatigue Syndrome Chronic 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

12. Chronic Fatigue Syndrome Chronic Fatigue Syndrome Four of the following criteria necessary 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

13. Chronic Fatigue Syndrome Chronic Fatigue Syndrome (6)New headache (6)New headache (7)Unrefreshing sleep (7)Unrefreshing sleep (8)Post-exertion fatigue lasting>24 hours (8)Post-exertion fatigue lasting>24 hours

14. Other Diseases Associated With Fatigue Psychiatric Psychiatric Endocrine/ Metabolic Endocrine/ Metabolic Cardio-Pulmonary Cardio-Pulmonary Infection Infection Connective Tissue Disorders Connective Tissue Disorders Sleep Disorders Sleep Disorders Neoplastic/Hematologic Neoplastic/Hematologic

15. Mnemonic P S V I N D I C A T E P S V I N D I C A T E

16. History Crucial to appropriate dx Crucial to appropriate dx Open-ended questions to appreciate patient’s understanding of illness Open-ended questions to appreciate patient’s understanding of illness Establishing therapeutic alliance which Establishing therapeutic alliance which is essential to dx and rx. is essential to dx and rx.

17. History What exactly is the patient’s experience? What exactly is the patient’s 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 factors which interfere with sleep? Are there emotional or disease factors which interfere with sleep? Is there snoring or apnea? Is there snoring or apnea?

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

19. History Are there B symptoms: Fever, night sweats, weight loss, anorexia Are there B symptoms: Fever, night sweats, weight loss, anorexia Are there symptoms related to specific organ symptoms? Are there symptoms related to specific organ symptoms? Remember the IMPORTANCE OF NOCTURNAL SYMPTOMS Remember the IMPORTANCE OF NOCTURNAL SYMPTOMS

20. History Are there symptoms of DEPRESSION? Are there symptoms of DEPRESSION? MSIGECAPS MSIGECAPS Are there ongoing stresses? Are there ongoing stresses?

21. Physical Examination Physical Examination General Appearance General Appearance Vital Signs (Blood pressure, heart rate and rhythm,?pallour) Vital Signs (Blood pressure, heart rate and rhythm,?pallour) ?Lymphadenopathy, ?hepatomegaly, ??splenomegaly (neoplasm lymphoma,mononucleosis) ?Lymphadenopathy, ?hepatomegaly, ??splenomegaly (neoplasm lymphoma,mononucleosis) ?Rales (interstitial lung disease, CHF) ?Rales (interstitial lung disease, CHF)

22. Physical Examination Physical Examination ?New cardiac murmur (endocarditis) ?New cardiac murmur (endocarditis) ?Thyroid enlargement ((hypo/hyperthyroid) ?Thyroid enlargement ((hypo/hyperthyroid) ?Edema (Hepatic, renal, cardiac,nutritional disorders) ?Edema (Hepatic, renal, cardiac,nutritional disorders)

23. Lab Investigations CBC CBC ESR ESR TSH TSH PREGNANCY TEST PREGNANCY TEST SCREENING CHEMISTRY SCREENING CHEMISTRY URINALYSIS URINALYSIS OTHER TESTS ONLY WHEN INDICATED OTHER TESTS ONLY WHEN INDICATED

24. Treatment of Fatigue Treatment of Fatigue Importance of Physician’s Commitment: Importance of Physician’s Commitment: Patients who believe that symptoms are related to modifiable factors (workload, financial issues, emotionally overburdened) more likely to improve than those who relate to organic factors e.g. virus. Patients who believe that symptoms are related to modifiable factors (workload, financial issues, emotionally overburdened) more likely to improve than those who relate to organic factors e.g. virus.

25. Treatment of Fatigue Treatment of Fatigue Patients are actually seeking recognition and support rather than investigation. Patients are actually seeking recognition and support rather than investigation.

26. Treatment of Fatigue Treatment of Fatigue Treat underlying Disease including sleep disorders Treat underlying Disease including sleep disorders Anti-depressants for depression Anti-depressants for depression Regular physical activity: walking and aerobics are the most benficial interventions Regular physical activity: walking and aerobics are the most benficial interventions Short naps Short naps

27. Treatment of Fatigue Treatment of Fatigue Caffeine, modafanil for sleep disorders; e.g related to shift work Caffeine, modafanil for sleep disorders; e.g related to shift work Sustaining inter-personal relationships, returning to work / time off work Sustaining inter-personal relationships, returning to work / time off work Yoga, group therapy, stress management decrease fatigue in patients with cancer Yoga, group therapy, stress management decrease fatigue in patients with cancer Adequate sleep: ?amitriptyline ?trazodone Adequate sleep: ?amitriptyline ?trazodone

28. Treatment of Fatigue Treatment of Fatigue Schedule regular visits to validate distress and not minimize it Schedule regular visits to validate distress and not minimize it CBT might be useful in treating chronic fatigue. CBT might be useful in treating chronic fatigue.

29. 51 yo woman with fatigue HPI: This is a 51 yo woman with a c/o severe fatigue, pain and swelling in her joints and muscles. Pain in the lateral thighs causes a giving way feeling. There is a concern about pain and swelling in her knees, legs,arms, feet and hands. Back and neck discomfort. Poor sleep. HPI: This is a 51 yo woman with a c/o severe fatigue, pain and swelling in her joints and muscles. Pain in the lateral thighs causes a giving way feeling. There is a concern about pain and swelling in her knees, legs,arms, feet and hands. Back and neck discomfort. Poor sleep.

30. Past History Carcinoma of the bowel with resection and no adjuvant Rx required. Carcinoma of the bowel with resection and no adjuvant Rx required. Hypothyroidism Hypothyroidism Perimenopausal Perimenopausal

31. Medications Synthroid 0.125 mgs. Synthroid 0.125 mgs.

32. Social Hx Works in a school with children with behavioural problems and learning disabilities Works in a school with children with behavioural problems and learning disabilities Very committed to job but emotionally draining. Very committed to job but emotionally draining. Stresses in personal family life Stresses in personal family life

33. 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?

34. Fatigue – 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 lab work will compliment the history. A screening physical exam and basic lab work will compliment the history. Therapeutic relationship is essential to an accurate dx. and improvement Therapeutic relationship is essential to an accurate dx. and improvement

35. Questions?