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Fatigue, Emergency Medicine

Basics

Description

- The specific mechanisms of fatigue are unknown. - Hematologic: - Endocrine: - Thyroid disorders - Adrenal insufficiency - Diabetes - Pregnancy

- Sleep disorders: - Cardiac and pulmonary disorders - Infections acute and chronic - Rheumatic and autoimmune disorders - Nutritional deficiencies including electrolyte abnormalities - Physical inactivity and deconditioning - Medications - Chronic fatigue syndrome: - Symptom complex defined by the CDC - Severe chronic fatigue lasting >6 mo - Not explained by any medical or psychiatric diagnosis - Presence of 4 or more of the following 8 symptoms: - Headache - Arthralgias - Sleep disturbances - Lymphadenopathy - Exercise intolerance - Myalgias - Impaired memory/concentration - Sore throat

- A complete physical exam should be focused on trying to identify an underlying cause for patients symptoms. No physical findings are specific to fatigue. - A partial list of physical exam findings which may suggest an underlying cause include: - Vital signs - HEENT - Pupils for evidence of toxidrome - Sclera for icterus in liver disease - Conjunctiva pale in anemia - Thyroid for enlargement, pain, or nodule that would suggest dysfunction

- Metabolic: - Electrolyte abnormalities - Mitochondrial diseases - Bromism

- Hematologic: - Anemia - Hypovolemia - Hemoglobinopathy

- Neurologic: - Multiple sclerosis - Cerebrovascular accident - Amyotrophic lateral sclerosis

- Cardiovascular: - Pulmonary: - Pneumonia - Chronic obstructive pulmonary disease - Asthma - Sleep apnea

- GI: - Reflux - Peptic ulcer disease - Liver disease

- Psychiatric: - Major depression - Anxiety - Grief - Stress

- Medication related: - Drug interactions - Commonly caused by BP, cardiovascular, psychiatric, and narcotic medications

  • A subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest
  • Fatigue occurs with or without objective findings on physical exam.
  • Fatigue is a common complaint in people with and without systemic disease, which makes this complaint a challenge to practicing physicians.

Etiology

  • The specific mechanisms of fatigue are unknown.
  • Hematologic:
  • Endocrine:Thyroid disordersAdrenal insufficiencyDiabetesPregnancy
  • Malignancy:
  • Psychiatric:Chronic painEmotional distressDepressionEating disordersChemical dependencyWithdrawal syndromes
  • Sleep disorders:
  • Cardiac and pulmonary disorders
  • Infections acute and chronic
  • Rheumatic and autoimmune disorders
  • Nutritional deficiencies including electrolyte abnormalities
  • Physical inactivity and deconditioning
  • Medications
  • Chronic fatigue syndrome:Symptom complex defined by the CDCSevere chronic fatigue lasting >6 moNot explained by any medical or psychiatric diagnosisPresence of 4 or more of the following 8 symptoms:HeadacheArthralgiasSleep disturbancesLymphadenopathyExercise intoleranceMyalgiasImpaired memory/concentrationSore throat

Diagnosis

Signs and Symptoms

  • Fatigue is a subjective complaint of exhaustion or tired sensation that interferes with normal activities of life, and symptoms do not resolve with sleep.
  • There are no specific signs of fatigue, but frequently physical signs may hint at the underlying cause of complaint.

History

  • Onset, pattern, duration of fatigue
  • Associated symptoms: Fever, night sweats, weakness, dyspnea, weight loss/gain, sleep patterns
  • Past medical and surgical history
  • Psychiatric history: Emotional and mental stressors, depression
  • Social history: Alcohol, drug use, major life events
  • Medications
  • Full review of systems

Physical Exam

  • A complete physical exam should be focused on trying to identify an underlying cause for patients symptoms. No physical findings are specific to fatigue.
  • A partial list of physical exam findings which may suggest an underlying cause include:Vital signsHEENTPupils for evidence of toxidromeSclera for icterus in liver diseaseConjunctiva pale in anemiaThyroid for enlargement, pain, or nodule that would suggest dysfunctionHeart: Murmurs or S3 may suggest LV dysfunction.Lung: Abnormal AP diameter or breath sounds may suggest chronic or acute lung disease.Abdomen: Tenderness or masses should be investigated.Skin: Rash may suggest infectious or autoimmune disease, lack of turgor may suggest dehydration, hyperpigmentation in Addison disease.Neurologic: True weakness or areflexia may suggest neuromuscular disorder, all new focal weakness should be investigated.Musculoskeletal: Indwelling IV lines or dialysis catheters should prompt investigation of electrolyte abnormality or occult bacteremia.

Essential Workup

  • Because fatigue is a subjective complaint, the essential workup is directed at identification of an underlying cause.

Diagnosis Tests & Interpretation

Lab

  • Lab evaluation should be directed by findings of history and physical exam.
  • CBC:Screen for anemia or leukemia.
  • Serum glucose:Both hyperglycemia and hypoglycemia can present with fatigue.
  • Pregnancy test
  • Electrolytes with BUN/creatinine
  • Thyroid-stimulating hormone:Screen for hypothyroidism.
  • Urine drug screen

Imaging

Imaging/special test: Special tests are reserved for evaluation of abnormal physical exam findings or history suggesting further evaluation.

Diagnostic Procedures/Surgery

Any diagnostic procedures considered should be reserved for evaluation of abnormal physical exam findings or history suggesting further evaluation.

Differential Diagnosis

  • Infection:BacteremiaUrosepsisPneumoniaViral syndromesAbscessEpstein-Barr virus, monospotCytomegalovirusHIVHuman herpesvirus 6
  • Immunologic/connective tissue:Rheumatologic (rheumatoid arthritis, systemic lupus erythematosus, juvenile rheumatoid arthritis)OsteoarthritisFibromyalgiaMyasthenia gravisLambert-Eaton syndrome
  • Neoplastic:Solid or hematologic cancers
  • Metabolic:Electrolyte abnormalitiesMitochondrial diseasesBromism
  • Hematologic:AnemiaHypovolemiaHemoglobinopathy
  • Endocrine:Hyperthyroid or hypothyroidAdrenal insufficiencyDiabetesHypoglycemia
  • Neurologic:Multiple sclerosisCerebrovascular accidentAmyotrophic lateral sclerosis
  • Cardiovascular:
  • Pulmonary:PneumoniaChronic obstructive pulmonary diseaseAsthmaSleep apnea
  • GI:RefluxPeptic ulcer diseaseLiver disease
  • Autonomic dysfunction
  • Lifestyle:Excessive or insufficient exerciseObesity
  • Psychiatric:Major depressionAnxietyGriefStress
  • Medication related:Drug interactionsCommonly caused by BP, cardiovascular, psychiatric, and narcotic medications
  • Dehydration

Treatment

Pre-Hospital

Evaluate vital signs:

  • Collect relevant information that could help psychosocial evaluation.

Initial Stabilization/Therapy

  • ABCs
  • Administer supplemental oxygen for hypoxia.
  • IV fluid bolus for signs of dehydration

Ed Treatment/Procedures

  • Treatment should be directed to correction of the underlying cause of fatigue:Identify and treat any infectious process.Correct metabolic and hematologic disturbances.Diagnose progressive neurologic disease and acute psychiatric crisis.Initiate workup for endocrine and neoplastic disease.Stop any offending medications or toxins.
  • Most cases will not have identifiable cause, so reassurance and close follow-up is required.
  • Recommend appropriate diet, exercise regimen, and consistent sleep cycles.

Medication

First Line

Medication should be reserved for treatment of the underlying cause of symptoms.

Follow-Up

Disposition

Admission Criteria

  • Underlying disease requiring IV medication or monitoring
  • Failure to thrive as outpatient
  • Unable to provide for self

Discharge Criteria

  • Able to care for self
  • Serious disturbances have been excluded.
  • Adequate follow-up is arranged.

Issues for Referral

Most patients who are evaluated for fatigue in the ED should be referred:

  • When the cause of a patients fatigue symptoms have been clearly identified, referral should be directed to the appropriate specialist.
  • When the cause of a patient's fatigue symptoms are not clearly identified, a primary care referral is indicated.

Pearls and Pitfalls

  • Fatigue is a subjective symptom complex, and a complete history and physical exam are needed.
  • Beware of patients with unreliable history and physical exam. The elderly, children, intoxicated, and those with decreased mental ability may all have life-threatening disease and present with a complaint of fatigue.

Additional Reading

  • Kitai E, Blumberg G, Levy D, et al. Fatigue as a first-time presenting symptom: Management by family doctors and one year follow-up. Isr Med Assoc J. 2012;14(9):555-559.
  • Manzullo EF, Escalante CP. Research into fatigue. Hematol Oncol Clin North Am. 2002;16(3):619-628.
  • Mawle AC. Chronic fatigue syndrome. Immunol Invest. 1997;26(1-2):269-273.
  • Morrison RE, Keating HJ 3rd. Fatigue in primary care. Obstet Gynecol Clin North Am. 2001;28(2):225-240, v-vi.
  • Nemec M, Koller MT, Nickel CH, et al. Patients presenting to the emergency department with non-specific complaints: The Basel Non-specific Complaints (BANC) study. Acad Emerg Med. 2010;17(3):284-292.

Codes

ICD9

  • 729.1 Myalgia and myositis, unspecified
  • 780.71 Chronic fatigue syndrome
  • 780.79 Other malaise and fatigue
  • 300.5 Neurasthenia
  • 719.49 Pain in joint, multiple sites

ICD10

  • M79.1 Myalgia
  • R53.82 Chronic fatigue, unspecified
  • R53.83 Other fatigue
  • F48.8 Other specified nonpsychotic mental disorders
  • M25.50 Pain in unspecified joint

SNOMED

  • 84229001 Fatigue (finding)
  • 52702003 Chronic fatigue syndrome (disorder)
  • 68962001 Muscle pain (finding)
  • 442099003 Psychogenic fatigue (finding)
  • 57676002 Joint pain (finding)