1. FATIGUE

2. Objectives:
1 Definition Classification Causes of Fatigue Practical approach of Fatigue Red flags of fatigue Chronic Fatigue Syndrome Treatment.

3. Fatigue is the subjective complaint of tiredness or diminished energy level to the point that interferes with normal and usual activity.
Among the most common presenting complaints to family physicians.
Bimodal distribution by age : first peak in late teens/ early 20s; second peak after 60. Women present with fatigue > than men.

4. Classification
Acute fatigue: Fatigue of recent onset After stressful life experiences Because of sleep deprivation Because of common illnesses or conditions Because of medication side effects

5. Prolonged fatigue: Fatigue lasting at least 1 month.
Chronic fatigue: Unexplained fatigue lasting at least 6 months. In most cases, physician is unable to identify a specific cause Chronic fatigue syndrome – severe disabling fatigue at least 6 months duration and a combination of symptoms, include self-reported problems with concentration and short-term memory, sleep disturbances , musculoskeletal pain.

6. Causes of Fatigue
Psychological Physical Lifestyle causes Unexplained fatigue and Chronic fatigue syndrome

7. Psychological causes
60-80% of patients of chronic fatigue Usually more than 6 months, and fluctuates in severity, it also can be acute Identifiable stressors , non –supportive family structure, or mood disorder may be found.

8. Psychological causes
- Patients usually have a sleep disturbance i.e. insomnia or early morning awakening Worse in the morning and may be decreased by activity Adjustment reaction to life changes ( death of family members, marital status change) and substance abuse ( caffeine, alcohol, illicit drugs).

9. Lifestyle causes
Results from conditions that cause most of people to be fatigued, e.g. sleep deprivation Common among mothers of newborn, shift workers, over-exercising, and medical students

10. Physical causes
- Often present more abruptly, and show a progressive course The most common disorders- DM, Acute infections, CVD, and Lung disease Medication side effects ( analgesics, psychotropics, antihypertensives, antihistamines.

11. Physical causes
- Fatigue is less in the morning and worsened with activity More specific complaints, physical exam., may show evidence of underlying disease Sleep disturbance is secondary to the disease, secondary depression may develop.

14. Practical approach
History Ask about : 1)Time course ( onset/ duration) ) Aggravating and relieving factors ) Associated symptoms (constitutional symptoms, system-specific symptoms) ) Impact of fatigue on relationships, work, and leisure activities

15. 5) Environmental stress: personal, family, occupational, financial
5) Environmental stress: personal, family, occupational, financial )Medications: prescribed or OTC )Personal habits and behaviors: sleep, diet, exercise, alcohol or recreational drug use

16. Physical examination
Complete physical exam should be performed General inspection: body habits, skin colour , hair, sclera, nails Mental status Neurologic Musculoskeletal Cardiovascular

18. Respiratory Abdominal Rectal Endocrine
If diagnosis uncertain

19. Level one- Laboratory evaluation
Complete blood count ESR Chemistry panel Thyroid testing Pregnancy test Age/ gender- appropriate cancer screening ( Pap smear, mammography)
Testing suggests etiology - further evaluation/ management
Testing normal Consider level two laboratory tests .

20. Level two-Laboratory tests
-Chest X-ray ( adenopathy , tumors infection, CHF) ECG ( silent ischemia) Serologies for rheumatic diseases ( RF, ANA..) Drug screen for unreported substances. - HIV, HCB ab, PPD, VDRL
Testing normal Consider Chronic fatigue syndrome ; Or chronic idiopathic fatigue

22. Chronic Fatigue syndrome
Also called CFS/ME( Myalgic Encephalomyelitis) CFS includes both an encephalitic component ( cognitive difficulties) and a skeletal muscle component The cause is unknown

24. Diagnosis
Historical criteria: Unexplained fatigue > 6 months accompanied by cognitive dysfunction

25. Major criteria:
Major criteria: New onset persistent or relapsing fatigue not previously present, sufficient to reduce daily activity by 50% or more, lasting at least 6 weeks Exclusion of other conditions.

26. Physical criteria
1.Low grade fever Non-exudative pharyngitis Palpable or tender anterior or posterior cervical or axillary nodes (2 cm in diameter)

27. Minor criteria:
1.Mild fever (37,5-38,6) 2.Sore throat. 3.Painful cervical or axillary lymph nodes 4.Unexplained generalized muscle weakness 5.Myalgia 6.Prolonged >24h generalized fatigue after previously tolerated exercise 7.Generalized headaches 8.Migratory arthralgia without joint swelling or redness. 9.Neuropsychiatric complaints ..inability to concentration, depression, confusion. 10.Sleep disturbances

28. Symptoms of CFS Percentage% Symptoms 60-95 % Low-grade fever 90 %
Difficulty concentrating
35-85 %
Headaches
50-75 %
Pharyngitis
30-40 %
Painful Lymph nodes

29. Muscle pain
20-95 %
Arthralgias
40-50%
Difficulty sleep
15-90%
Impaired cognition
50-85%
Depression
70-85%
Anxiety
50-70%
Postexertional malaise
50-60%

30. Treatment
- Life style changes ( improve sleep habits) Graded exercise therapy Medications ( tricyclics or SSRIs) Counseling ( Supportive psychoterapy, Cognitive-behavioral therapy) and patient education Alternative complementary therapy ( acupuncture, massage)

31. THANK’S