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Fatigue, Etiology-續, Etiology, Approach - Coggle Diagram
Fatigue
定義
- Fatigue refers to the subjective human experience of physical and mental weariness, sluggishness, low energy, and exhaustion
- 指的是病人身心疲倦, 呆滯, 精力不足,和疲憊的主觀感覺
- practically defined as difficulty initiating or maintaining voluntary mental or physical activity
鑑別診斷
- weakness:MP下降，most patients complaining of fatigue are not truly weak when direct muscle power is tested
- somnolence: refers to sleepiness in the context of disturbed sleep-wake physiology
- dyspnea on exertion
ps.病人可能用fatigue來描述其他三種情況，需鑑別診斷
Etiology-續
Obesity
- Obesity is associated with fatigue and sleepiness independent of the presence of obstructive sleep apnea. Obese patients under-going bariatric surgery experience improvement in daytime sleepiness sooner than would be expected if the improvement were solely the result of weight loss and resolution of sleep apnea. A number of other factors common in obese patients are likely contributors as well, including physical inactivity, diabetes, and depression.
- 肥胖
- 以及相關共病: physical inactivity, diabetes, and depression.
Physical Inactivity
- Physical inactivity is associated with fatigue,
and increasing physical activity can improve fatigue in some patients.
Malnutrition
- Although fatigue can be a presenting feature of malnutrition, nutritional status may also be an important comorbidity
Infection
- Both acute and chronic infections commonly lead to fatigue as part of the broader infectious syndrome.
- Evaluation for undiagnosed infection as the cause of unexplained fatigue, and particularly prolonged or chronic fatigue, should be guided by the history, physical examination, and infectious risk factors, with particular attention to risk for tuberculosis, HIV, chronic hepatitis, and endocarditis. Infectious mononucleosis may cause prolonged fatigue that persists for weeks to months following the acute illness, but infection with the Epstein-Barr virus is only very rarely the cause of unexplained chronic fatigue.
- 急性或慢性感染
- 無法解釋, 延長, chronic 的fatigue-->focus on: TB, HIV, 慢性肝炎, 心內膜炎
- Infectious mononucleosis:可能導致在急性感染後fatigue持續數周~月
- EBV很少是慢性感染引起的fatigue的原因
Drugs
- Many medications, drugs, drug withdrawal, and chronic alcohol use can all lead to fatigue. Medications that are more likely to be causative include antidepressants, antipsychotics, anxiolytics, opiates, antispasticity agents, antiseizure agents, and beta blockers.
- 長期喝酒
- 抗憂鬱藥, 抗精神病藥, 抗焦慮藥, 抗痙攣藥, 抗癲癇藥, opiate, beta-blocker
Cardiovascular and Pulmonary
- Fatigue is one of the most taxing symptoms reported by patients with congestive heart failure and chronic obstructive pulmonary disease and negatively affects quality of life.
Malignancy
- Fatigue, particularly in association with unexplained
weight loss, can be a sign of occult malignancy, but cancer is rarely identified in patients with unexplained chronic fatigue in the absence of other telltale signs or symptoms. Cancer-related fatigue is experi-enced by 40% of patients at the time of diagnosis and by >80% at sometime in the disease course.
- Malignancy: chronic fatigue+體重下降+器官症狀
Hematologic
- Chronic or progressive anemia may present with
fatigue, sometimes in association with exertional tachycardia and breathlessness. Anemia may also contribute to fatigue in chronic
illness. Low serum ferritin in the absence of anemia may also cause fatigue that is reversible with iron replacement.
- Anemia: s/s: exertional tachycardia and breathlessness
- also contribute to fatigue in chronic disease
Systemic Inflammatory/Rheumatologic Disorders
- Fatigue is a prominent complaint in many chronic inflammatory disorders, including systemic lupus erythematosus, polymyalgia rheumatica, rheumatoid arthritis, inflammatory bowel disease, anti-neutrophil cytoplasmic antibody (ANCA)—associated vasculitis, sarcoidosis, and Sjögren’s syndrome, but is not usually an isolated symptom. Fatigue is also associated with primary immunodeficiency diseases.
- chronic inflammatory disorders: 但通常不是唯一的症狀
- SLE, polymyalgia rheumatica, RA, IBD, ANCA-associated vasculitis, sarcoidosis, and Sjögren’s syndrome
- primary immunodeficiency diseases.
Pregnancy
- Fatigue is very commonly reported by women during all stages of pregnancy and postpartum.
Disorders of Unclear Cause
- Chronic fatigue syndrome (Chap. 442) and fibromyalgia (Chap. 366) incorporate chronic fatigue as part of the syndromic definition when present in association with a number of other inclusion and exclusion criteria, as discussed in the respective chapters. Chronic multisymptom illness, also known as Gulf-War syndrome, is another symptom complex with prominent fatigue; it is most commonly, although not exclusively, observed in
veterans of the 1991 Gulf war conflict (Chap. S6). Idiopathic chronic fatigue is used to describe the syndrome of unexplained chronic fatigue in the absence of enough additional clinical features to meet the diagnostic criteria for chronic fatigue syndrome.
- 慢性疲勞症候群
- fibromyalgia
- Chronic multisymptom illness, also known as Gulf-War syndrome
- Idiopathic chronic fatigue
Etiology
Liver and Kidney Disease
- Both chronic liver failure and chronic kidney disease can cause fatigue. Over 80% of hemodialysis patients complain of fatigue, which makes it one of the most common symptoms reported by patients in chronic kidney disease.
- Chronic liver failure
- Chronic kidney disease
Sleep Disorders
- Obstructive sleep apnea is an important cause of excessive daytime sleepiness in association with fatigue and should be investigated using overnight polysomnography, particularly in those with prominent snoring, obesity, or other predictors of obstructive sleep apnea (Chap. 291). Whether the cumulative sleep deprivation that is common in modern society contributes to clinically apparent fatigue is not known (Chap. 27).
- Obstructive sleep apnea(阻塞性睡眠呼吸中止症): s/s:肥胖, 嚴重打鼾, 其他相關危險因子
- 失眠
Psychiatric Disease
- Fatigue is a common somatic manifestation of many major psychiatric syndromes, including depression, anxiety, and somatoform disorders. Psychiatric symptoms are reported in more
than three-quarters of patients with unexplained chronic fatigue. Even in patients with systemic or neurologic syndromes in which fatigue is independently recognized as a manifestation of disease, comorbid psychiatric symptoms or disease may still be an important source of interaction.
- Fatigue是常見的精神性疾病的表現(somatic manifestation)
- 超過1/3的chronic fatigue 是精神性疾病
- 即使已經診斷systemic disease or neurologic syndromes 是造成fatigue的原因, 共病的精神性疾病依然是fatigue的重要來源
Neurologic Disease
- Patients complaining of fatigue often say they feel weak, but upon careful examination objective muscle weak-ness is rarely discernible. If found, muscle weakness must then be localized to the central nervous system, peripheral nervous system, neuromuscular junction, or muscle and appropriate follow-up studies obtained (Chap. 21).
- Fatigability of muscle power is a cardinal manifestation of some neuromuscular disorders such as myasthenia gravis and
is distinguished from fatigue by finding clinically apparent diminution of the amount of force that a muscle generates upon repeated contrac-
tion (Chap. 440). Fatigue is one of the most common and bothersome symptoms reported in multiple sclerosis (MS) (Chap. 436), affecting
nearly 90% of patients; fatigue in MS can persist between MS attacks and does not necessarily correlate with magnetic resonance imaging
(MRI) disease activity. Fatigue is also increasingly identified as a troublesome feature of many neurodegenerative diseases, including
Parkinson’s disease, central dysautonomias, and amyotrophic lateral sclerosis. Fatigue after stroke is a well-described but poorly understood
entity with a widely varying prevalence. Episodic fatigue can be a premonitory symptom of migraine. Fatigue is also a frequent result of
traumatic brain injury, often occurring in association with depression and sleep disorders.
- 雖然fatigue伴隨mp下降很少見, 但一但發現伴隨MP下降，則必是神經系統疾病(CNS,PNS,NMJ,M), 需做進一步檢查
- 多發性硬化症
- neurodegenrative disease: ex. 帕金森氏症, central dysautonomias(自主神經異常), ALS(amyotrophic lateral sclerosis)
- Stroke
- episodic fatigue: migraine的前驅症狀
- traumatic brain injury: 常伴隨depression and sleep disorder
Endocrine Disorders
- Fatigue, sometimes in association with true muscle weakness, can be a heralding symptom of hypothyroidism, particularly in the context of hair loss, dry skin, cold intolerance, constipation, and weight gain. Fatigue associated with heat intolerance, sweating, and palpitations is typical of hyperthyroidism.
- Adrenal insufficiency can also manifest with unexplained fatigue as a primary or prominent symptom, often with anorexia, weight loss, nausea, myalgias, and arthralgias; hyponatremia, hyperkalemia, and hyperpigmentation may be present at time of diagnosis.
- Mild hypercalcemia can cause fatigue, which may be relatively vague, whereas severe hypercalcemia can lead to lethargy, stupor, and coma.
- Both hypoglycemia and hyperglycemia can cause lethargy, often in association with confusion; diabetes mellitus, and in particular type 1 diabetes, is also associated with fatigue independent of glucose levels.
- Fatigue may also accompany Cushing’s disease, hypoaldosteronism, and hypogonadism.
- Low vitamin D status has also been associated with fatigue.
- 甲狀腺功能低下: 前驅症狀:fatigue伴MP下降, s/s:掉髮, 皮膚乾燥, 怕冷, 便祕, 體重增加
- 甲狀腺亢進: s/s: 怕熱, sweating, palpitation
- Adrenal insufficiency : s/s: 厭食, 體重下降, 噁心, 肌肉痛, 關節痛.低血鈉, 低血鉀, hyperpigmentation
- 高血鈣: 輕微高血鈣可導致fatigue, 嚴重高血鈣會導致lethargy, stupor, coma
- 低血糖, 高血糖: s/s:常伴隨confusion. 糖尿病患者
- Cushing's disease(腦下腺)
- hypoaldosteronism
- hypogonadism
- Vit D 缺乏
-->腦下腺,甲狀腺, 腎上腺,性腺, 血糖, 血鈣, Vit D
Approach
Pathologic approach
- infectious
- non-infectious inflammatory
- neoplasm
- circulatory
- metabolic/endocrine
- hematologic
- degenerative
- physical/chemical injury
- other
+一點systemic approach
cardiovascualar
respiratory
gastrointestinal
genitourinary
neuropsychiatric
- 病史:
- 發生時間, 病程的持續進展狀況,持續多久, 伴隨症狀,加重緩解因子
- social history很重要: 日常生活的活力, 運動, 飲食/胃口, 睡眠，身心狀況
- 特定器官症狀-->系統回顧對於特殊器官的病灶可以提供重要線索
- 藥物史
- 憂鬱及失智的特徵
- 旅遊史, 可能暴露的感染媒介
- 過去病史-->可能可以解釋現在的表現跟之前疾病的關聯性
- 排除somnolence, weakness, DOE
- 伴隨症狀
->
發燒與體重下降-->感染, malignancy
逐漸變喘-->心,腎,肺
關節痛-->inflammatory
之前診斷過的腫瘤-->復發or轉移
瓣膜性心臟病, 心肌病變-->decompensated?
甲狀腺切除-->甲低
睡眠呼吸中止症-->常忽略
藥物使用的改變-->是一定要想到的, 不管是最近開始使用或停用，幾乎所有的藥物都有可能會造成fatigue。但是，這類病人通常會是因為一個新的不舒服而開始使用新的藥物使用，所以我們不能排除其他原因的可能。
多重用藥及不正確的使用劑量-->是常造成fatigue的原因, 尤其是老人
發生的時間很重要
- 緩慢的以數月~數年表現-->通常和逐漸發生的器官衰竭及內分泌疾病相關
- 較快的時間，以數周到數月表現-->通常比較像感染或是malignancy
PE:
- 根據病史來FOCUS
- 應特別評估體重及營養狀態, 淋巴結病變, 肝脾腫大, 腹部腫瘤, 是否蒼白, 皮疹, 心衰竭, 新的心雜音,疼痛的關節, 肌肉無力 or 神經學症狀
Lab
->小哈