Tired All The Time (TATT) in General Practice www.nickdattani.com

Aims How to define tiredness History taking Examination When to be concerned (red flags) Diagnosis Management

TATT Definition Is this a dangerous diagnosis – can we read code it properly? Do we take the persons word for it?

TATT Definition Fatigue is a normal part of life, but it can also be a symptom of disease, including serious illnesses. Chronic fatigue occurs in all age groups, including children. Women, minority groups, and people with lower educational and occupational statuses have a higher prevalence of chronic fatigue. 5-7% of patients attending primary care have a primary complaint of fatigue. Almost three quarters of consultations for fatigue are isolated episodes, with no follow-up consultations. Investigations are carried out in only half of patients complaining of fatigue and few of these tests show abnormal results. A diagnosis is made in less than half of patients. Many of the diagnoses are descriptive - eg, stress.

TATT Information A survey from the Royal College of Paediatrics and Child Health found that the prevalence of medically unexplained severe fatigue over three months in 5- to 19-year-olds was 62 per 100,000. Cases were predominantly adolescent girls and were more likely to come from practices in less deprived areas, which could reflect consulting behaviors.

TATT History Taking How long has it gone on for? Are they tired all the time or only sometimes? If sometimes, when? What is their lifestyle like? Do they sleep properly? Are they happy or stressed/depressed? Is their weight stable? What medication/drugs do they take? Do they consume alcohol? Have they experienced night sweats? Have they suffered any change in bowel habit or rectal bleeding? Are they breathless? If so, do they get breathless at rest or on exertion? Do they experience orthopnoea or palpitations? Do they have a cough or wheeze? Have they got symptoms of diabetes? A menstrual history is essential in women, while features of prostatism should be asked about in men.

'Listen to the patient. He (or she) is telling you the diagnosis.' TATT History Taking 'Listen to the patient. He (or she) is telling you the diagnosis.'

TATT Examination Unless the cause of the tiredness is obvious, a general examination is imperative. Of course, a clear explanation as to why you need to examine a patient for tiredness is essential. Does the patient look depressed, jaundiced, breathless, cachectic, pale or hypothyroid? Do they have finger clubbing, signs of endocarditis, tremor, Dupuytren's contracture, palmar erythema or an abnormal pulse when examining the hands? Moving to head and neck, is there evidence of conjunctival pallor, lymphadenopathy or goitre?

TATT Examination Examination of the heart may reveal evidence of cardiac failure, arrhythmia or a murmur. Features of fibrosis, effusion or primary, metastatic or paraneoplastic disease may be found on respiratory examination. When examining the abdomen, hepatomegaly may be suggestive of alcoholic or infective hepatitis, or malignancy. Splenomegaly can be caused by connective tissue diseases, haematological disease such as leukaemia and myelofibrosis and infections. A mass may be palpated in the abdomen suggestive of bowel cancer.

TATT Examination Women may require a pelvic examination. Depression screening questionnaires may be appropriate and recent evidence has shown these to have a good negative predictive value. PHQ /27 GAD /21 Bio assessment on EMIS

TATT Differential Diagnosis Constitutional: poor conditioning, pregnancy. Infection: TB, glandular fever. Malignancy: especially when associated with weight loss. Haematological: anaemia. Cardiovascular: ventricular dysfunction, IHD, arrhythmia, valve disease. Respiratory: obstructive/restrictive airways disease, sleep apnoea. Renal: failure. Drugs: beta-blockers, antihistamines. Endocrine: diabetes, hypothyroidism, Addision's. Neurological: Parkinson's disease, ME. Gastrointestinal: inflammatory bowel disease, liver disease, coeliac disease. Psychological: depression, alcoholism, illicit drugs, chronic fatigue, stress.

TATT Red Flags Significant weight loss. Lymphadenopathy with signs of malignancy (e.g., a lymph node that is non-tender, firm, hard, larger than 2 cm across, progressively enlarging, supraclavicular, or axillary). Haemoptysis —Lung cancer suspected. Dysphagia — suspected and GI (upper) cancer Rectal bleeding — GI (lower) cancer suspected. Breast lump — Breast cancer suspected. Postmenopausal bleeding —Gynaecological cancer suspected. Localizing/focal neurological signs. Symptoms and signs of inflammatory arthritis, vasculitis (such as giant cell arteritis and polymyalgia rheumatica) Symptoms and signs of cardiorespiratory disease Sleep apnoea

TATT Investigations Most patients complaining of feeling tired all the time will have a normal clinical examination. If there is no obvious cause, it is reasonable to organise a series of general blood tests. Ideally, tests should be tailored to the clinical picture. An FBC may reveal evidence of anaemia or infection. Renal failure and liver disease may present with fatigue. Thyroid function and blood glucose should also be checked. Hypercalcaemia may masquerade as depression and fatigue. An ESR may help rule out inflammatory diseases.

TATT Screening One thing that could be a differential that came up in a few resources that I thought was worth thinking about also…. Heart failure is not always easy to diagnose, but a normal ECG and chest X-ray virtually rules out left ventricular systolic dysfunction. An echocardiogram should otherwise be organised. An oxygen saturation reading may prove useful and sleep studies may be required.

TATT Suspected CFS (1) Suspect chronic fatigue syndrome (CFS)/myalgic encephalomyelitis or encephalopathy (ME) if both of the following criteria are met: The person has fatigue that has all of the following features: Persistent (for 4 months or longer) or recurrent. New or had a specific onset (that is, it is not lifelong). Unexplained by other conditions (including body mass index greater than 40 kg/m2). Has resulted in a substantial reduction in activity level. Characterized by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days).

TATT Suspected CFS (2) The person has one or more of the following symptoms: Difficulty with sleeping (such as insomnia, hypersomnia, unrefreshing sleep, or a disturbed sleep-wake cycle). Muscle or joint pain that is multi-site and without evidence of inflammation. Headaches. Painful lymph nodes without pathological enlargement. Sore throat.

TATT Suspected CFS (3) Cognitive dysfunction (such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organising thoughts, and information processing). Physical or mental exertion makes symptoms worse. General malaise or flu-like symptoms. Dizziness or nausea. Palpitations in the absence of identified cardiac pathology.

TATT Suspected CFS (4) The diagnosis of CFS/ME should be reconsidered if none of the following features are present: Post-exertional fatigue or malaise. Cognitive difficulties. Sleep disturbance. Chronic pain.

TATT Specific Tests (1) Offer the following routine first-line investigations: Full blood count. Erythrocyte sedimentation rate or C-reactive protein. Thyroid stimulating hormone. Random blood glucose. IgA tissue transglutaminase for coeliac disease (provided the person consumes gluten-containing foods).

TATT Specific Tests (2) Also consider offering the following additional investigations: U&Es, LFTs, Calcium — particularly if the person is obese, or is 60 years of age or older. Serum ferritin — in women of child-bearing age, as there is limited evidence that iron supplementation is effective even in the absence of anaemia. Testing for vitamin D deficiency Testing for glandular fever (infectious mononucleosis), such as by the monospot test) HIV test — if the person is at risk. Hepatitis serology — if the person is at risk. Testing for tuberculosis (chest radiography and sputum samples) pending referral

TATT Management (1) Try to establish a supportive therapeutic relationship. Try to offer an understandable explanation for tiredness/fatigue that: Absolves the person from blame but also offers ways for the person to take, or at least share, responsibility for managing the symptom. Is linked clearly to the person's specific concerns. Provides links between psychosocial and physical factors. Try to broaden the person's perception of tiredness/fatigue so that psychosocial causes and solutions are validated and considered along with biomedical causes. Identify and address modifiable psychological, social, and general health factors, including stress, work, personal relationships, pain, and alcohol.

TATT Management (2) Offer advice on sleep management. Provide general advice on sleep hygiene Discourage excessive sleep and daytime sleeping or naps. In relation to activity, rest, and relaxation, advise: Limiting the length of rest periods to 30 minutes at a time. Introducing low level physical and cognitive activities Avoiding unsupervised, or unstructured, vigorous exercise. Using relaxation techniques. Advise a well-balanced diet. Manage nausea by giving advice on eating little and often, snacking on dry starchy foods, and sipping fluids. Use anti-emetic drugs only if nausea is severe.

TATT Referrals (1) Referral to secondary care is likely to be required if a serious underlying physical cause is suspected or identified, such as Addison's disease, coeliac disease, HIV, hepatitis B or C, malignancy, renal failure, or sleep apnoea Refer adults with symptoms suggestive of chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy (CFS/ME) to specialist CFS/ME services: Within 6 months of presentation, if symptoms are mild. Within 3–4 months of presentation, if symptoms are moderate. Immediately, if symptoms are severe.

TATT Referrals (2) Refer to secondary care those people with persistent, unexplained tiredness/fatigue not meeting the criteria for CFS/ME if any of the following apply: There is significant uncertainty regarding the presence of an underlying physical cause. The person would benefit from the reassurance of a second opinion or from the thoroughness of a secondary care evaluation, and referral is not likely to reinforce unrealistic beliefs in a physical cause. The person may benefit from access to the structured and multidisciplinary care delivered by specialist CFS/ME services, or from a secondary care opinion for occupational reasons or disability benefits. Children and young people 17 years of age or younger should be referred to paediatrics within 6 weeks of presentation

TATT Complications What are the complications? Fatigue negatively impacts on work, family life, and social relationships. These patients need time and attention…

TATT Discussion Questions…?

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