Fatigue/Sleepiness

Fatigue-Sleepiness

• DDX:
  • – Depression
    
  • – Post-Traumatic Stress Disorder(PTSD)
    
  • – Colon Cancer
    
  • – Hypothyroid
    
  • – Obstructive Sleep Apnea (OSA)
    
  • – Diabetes Mellitus (DM)
    
  • – Sleep deprivation
• Physical Exam:
  • – VS: State (or WNL or WNL except…)
  • – General: Patient is in no acute distress
  • – HEENT exam (conjunctival pallor, oropharynx/palate, lymphadenopathy, thyroid exam): => No Conjunctival pallor, mouth and pharynx wnl
  • – Neck: No lymphadenopathy, thyroid normal
  • – Chest Exam: Auscultation – Clear breath sounds bilaterally/Clear breath sounds bilaterally
  • – Heart Exam: Auscultation – RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
  • – Abdomen Exam: Auscultation, Palpation, Percussion – Soft, nondistended, nontender, +BS, no hepatosplenomegaly
  • – Extremities Exam: No edema, normal DTRs in lower extremities (pallor, coolness at distal extremities)
  • – Consider rectal exam and occult blood testing
• Work-up:
  • – CBC with diff
    
  • – TSH/Free T4 (FT4)
    
  • – HIV/STD
    
  • – Urine Toxicology (Urine Tox)
    
  • – Glucose/HbA1c
    
  • – Urine Analysis

Adjustment Disorder

• Presentation:
  • – Stress-related, short-term, nonpsychotic disturbance
    
  • – Disproportionately overwhelmed or overly intense in their responses to given stimuli (divorce, new baby, move etc…)
    
  • – Begins w/in 3 months of stressor and symptoms lessen within 6 months upon stressor removal or new adaptation occurs
• Treatment:
  • Psychotherapy
  • Antidepressants
  • Anti-anxiety drugs

Colon cancer

• Presentation:
  • fatigue, weight loss, and constipation.
  • family history of colon cancer
• DDX:
  • – Colon cancer
    
  • – Hypothyroidism
    
  • – Renal failure
    
  • – Hypercalcemia
    
  • – Depression (Major Depressive Disorder (MDD))
• Work-up:
  • – Rectal exam, stool for occult blood
    
  • – CBC with diff, Electrolytes, Calcium, BUN/Cr, LFTs-AST/ALT, TSH
    
  • – Colonoscopy
    
  • – Barium enema
• Specialist:
  • Gastroenterologist
  • Oncologist
  • Surgery
• Treatment:
  • Chemotherapy
    • 5-Fluorouracil (5-FU)
    • Capecitabine (Xeloda) – pill form. Once in the body, it is changed to 5-FU when it gets to the tumor site.
    • Irinotecan (Camptosar)
    • Oxaliplatin (Eloxatin)
    • Trifluridine and tipiracil (Lonsurf), a combination drug in pill form
  • Surgery
    • LN dissection
    • Colectomy

Depression (Major Depressive Disorder (MDD))

• Presentation: (SIGECAPS)
  • Depressed Mood
  • Sleep decreased (Insomnia with 2-4 am awakening)
  • Interest decreased in activities (anhedonia)
  • Guilt or worthlessness (Not a major criteria)
  • Energy decreased
  • Concentration difficulties
  • Appetite disturbance or weight loss
  • Psychomotor retardation/Agitation
  • Suicidal thoughts
• DDX:
  • – Depression (Major Depressive Disorder (MDD))
    
  • – Adjustment disorder
    
  • – Hypothyroidism
    
  • – Anemia
• Work-up:
  • – CBC with diff, TSH
    
  • – HIV/STD testing (given husband’s possible risk factors)
• Specialist:
  • Clinical psychologist
  • Psychiatrist
  • Primary care provider (PCP)
• Treatments:
  • Therapy
    • CBT, Behavioral Therapy, Psychotherapy
  • Medication
    • Selective Serotonin Reuptake Inhibitor (SSRI)
    • Antidepressant, Anxiolytic
    • Antipsychotic
  • Electroconvulsive therapy

Diabetes Mellitus

• Presentation:
  • – fatigue, thirst, increased appetite, and polyuria
  • – Polyuria, Polydipsia, Polyphagia** (either DM or DI → DM = glucose in urine, high specific gravity, DI → dilute urine)
  • – Metabolic diseases → ↑ blood sugar levels over a prolonged period
  • – ↑ Blood sugar symptoms = frequent urination, ↑ thirst, and ↑ hunger
  • – Untreated, diabetes can cause many complications.
  • – Acute complications include diabetic ketoacidosis and nonketotic hyperosmolar coma.
  • – Serious long-term complications include heart disease, stroke, kidney failure, foot ulcers and damage to the eyes.
• Types:
  • Type 1 diabetes- chronic condition in which the pancreas produces little or no insulin.
  • Type 2 diabetes – chronic condition that affects the way the body processes blood sugar (glucose).
• DDX:
  • – Diabetes Mellitus
    
  • – Atypical depression
    
  • – Primary polydipsia
    
  • – Diabetes Insipidus
• Work-up:
  • – Glucose tolerance test, HbA1c
    
  • – Urinary Analysis
    
  • – CBC with diff, Electrolytes, Glucose, BUN/Cr
  • – DM if:
    • blood sugar level ≤ 126 mg/dl (7 mmol/l).
    • 2 random blood sugar tests > 200 mg/dl (11.1 mmol/l) with symptoms.
    • oral glucose tolerance test with results over 200 mg/dl (11.1 mmol/l).
    • A1c test > 6.5% on 2 separate days.
    • Fasting Glucose Test
      • Normal: Less than 100
      • Pre-diabetes: 100-125
      • Diabetes: 126 or higher
    • Random (anytime) Glucose Test
      • Normal: Less than 140
      • Pre-diabetes: 140-199
      • Diabetes: 200 or higher
    • A1c Test
      • Normal: Less than 5.7%
      • Pre-diabetes: 5.7 – 6.4%
      • Diabetes: 6.5% or higher
• Specialist:
  • Primary care provider (PCP)
  • Ophthalmologist
  • Endocrinologist
  • Nutritionist
• Preventative:
  • Influenza vaccine and Pneumococcal vaccine
• Treatment:
  • Self-care
    • Physical exercise, Quitting smoking, Weight loss, Nutrition counseling, Diabetic diet, and Dietary fiber
  • Medications
    • First line – Metformin (CI if GFR < 30)
    • Second line – Glitazone
    • Insulin Therapy
      • Basal Insulin
      • Basal with Bolus Insulin
      • Mixed Insulin

Diabetes Insipidus (DI)

• Presentation:
  • – Excretion of large amounts of severely diluted urine, which cannot be reduced when fluid intake is reduced.
  • – Denotes inability of the kidney to concentrate urine.
  • – DI is caused by a deficiency of antidiuretic hormone (ADH), aka vasopressin, or by an insensitivity of the kidneys to that hormone
  • – It can also be induced iatrogenically by the diuretic conivaptan
  • – Types:
    • Central diabetes insipidus – abnormality in the pituitary gland or hypothalamus (such as a tumor)
    • Nephrogenic diabetes insipidus – kidneys don’t properly respond to ADH
    • Gestational diabetes insipidus
    • Primary polydipsia
• Work-up
  • Water deprivation test
  • MRI – look for abnormalities in or near the pituitary gland
  • Genetic screening
• Treatment:
  • Self Care
    • Low sodium diet
    • Decrease Fluid Intake for Primary polydipsia
    • Increase Fluid Intake for Central diabetes insipidus
  • Supportive Care
    • IV fluids and Fluid replacement
  • Medication
    • Antidiuretic
      • Desmopressin (DDAVP, Minirin)
      • Synthetic hormone desmopressin for Gestational diabetes insipidus
    • Diuretic
      • HCTZ
      • Amiloride
      • Chlorothiazide

Generalized Anxiety Disorder (GAD)

• Presentation:
  • Worry WARTS
    
  • – Wound up
    
  • – Worn-out
    
  • – Absent minded
    
  • – Restless
    
  • – Touchy
    
  • – Sleepless
• Treatment:
  • Self Care
    • Limiting or stopping the use of caffeine.
    • Eating a healthy, well-balanced diet
    • Physical exercise, Stress management, and Relaxation techniques
  • Therapy
    • Mindfulness therapies, Cognitive behavioral therapy, Mindfulness, Psychoanalysis, and Psychotherapy
  • Medication
    • selective serotonin reuptake inhibitor (SSRI)
      • Citalopram (Celexa)
      • Escitalopram (Lexapro)
      • Fluoxetine (Prozac)
      • Fluvoxamine (Luvox, Luvox CR)
      • Paroxetine (Paxil, Paxil CR, Pexeva)
      • Sertraline (Zoloft)
      • Vilazodone (Viibryd)
    • serotonin and norepinephrine reuptake inhibitor (SNRI)
      • Effexor (venlafaxine)
      • Pristiq (desvenlafaxine)
      • Cymbalta (duloxetine)
    • anti-anxiety medication
      • Buspirone (Buspar)
    • Benzodiazepines – relieve acute anxiety

Hypercalcemia

• Presentation:
  • – Hypercalcemia is a disorder that most commonly results from malignancy or primary hyperparathyroidism.
    
  • – Other causes of ↑ calcium are less common and not considered until malignancy and PTH disease are r/o
• Treatment:
  • Supportive Care
    • IV fluids
  • Medication
    • Calcitonin
    •  Bisphosphonates
      • Zolendronic acid
  • Surgery
    • Parathyroidectomy

Hypothyroidism

• Presentation:
  • – fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
  • – Usually primary hypothyroidism – ↓ Thyroid hormone (TH) but secondary = ↓ TSH secreation or tertiary = ↓ TRH secretion
  • – In USA MCC – Autoimmune thyroid disease = Hashimoto thyroiditis
• – Mnemonic → AABBCDDEEFGHVS
  
  • – Arthralgia and Weakness/ Paresthesias/ Muscle Cramps → Peripheral Neuropathy and Carpal Tunnel Syndrome
    
  • – Anorexia → Decreased Appetite
    
  • – Bowel → Constipation
    
  • – Bradycardia → Slow Heart Rate
    
  • – Cold Intolerance → Dressed Inappropriately for Ambient Temperature
    
  • – Depressed → Mental Clouding and Impaired Memory
    
  • – Delayed DTRs
    
  • – Energy → No Energy/Fatigue (Drowsiness)/ Lethargy→ Somnolence →Uninterested, Immobile
    
  • – Eyebrows → Loss /thinning of lateral ⅓
    
  • – Facial →Periorbital puffiness
    
  • – Gain → Weight Gain
    
  • – Hair → Coarse/brittle hair, hair falling out
    
  • – Voice Hoarseness
    
  • – Swelling of face, hands, and legs
• DDX:
  • – Hypothyroidism
    
  • – Depression (Major Depressive Disorder (MDD))
    
  • – Diabetes
    
  • – Anemia
• Work-up:
  • – TSH, FT3, FT4
    
  • – CBC with diff
    
  • – Fasting Glucose, HbA1c
• Treatment:
  • Medication
    • Levothyroxine (Levo-T, Synthroid)

Obstructive Sleep Apnea (OSA)

• Presentation:
  • – fatigue and daytime sleepiness. snores heavily and naps 3-4 times per day but never feels refreshed. Hx of hypertension.
  • – Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.
  • – Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.
  • – Cessation for >10 seconds → ↓ O2 saturation → Episodes of breathing cessation for 10 seconds during sleep, 10 – 15 events per hour with ↓ O2 saturation
  • – Associated signs → Snoring, gasping, GI reflux (GERD), nocturia, excessive moving, night sweats, morning headaches, daytime sleepiness, sleep attacks
  • – Psychological: Slow thought process, memory impairment, inattention
• DDX:
  • – Obstructive Sleep Apnea (OSA)
    
  • – Hypothyroidism
    
  • – Chronic fatigue syndrome
    
  • – Narcolepsy
• Work-up:
  • – CBC with diff, TSH
    
  • – Nocturnal pulse oximetry
    
  • – Polysomnography
    
  • – ECG
• Specialist:
  • Primary care provider (PCP)
  • Sleep medicine
  • Otolaryngologist
• Treatment:
  • Self Care
    • Sleeping on side, Avoid alcohol, and Weight loss
  • Supportive Care
    • Continuous positive airway pressure (CPAP) and BiPap
  • Surgery
    • Tonsillectomy and Adenoid removal

Post-Traumatic Stress Disorder (PTSD)

• Presentation:
  • TRAUMA
    
  • T – Traumatic event exposure
    
  • R – Re-experience (1+)
    
  • A – Avoidance (3+)
    
  • U – Unable to function
    
  • M – Month or more of symptoms
    
  • A – Arousal increased (2+)
• DDX:
  • – Post-Traumatic Stress Disorder (PTSD)
    
  • – Depression (Major Depressive Disorder (MDD))
    
  • – Generalized Anxiety Disorder (GAD)
    
  • – Psychotic or delusional disorder
    
  • – Hypothyroidism
• Work-up:
  • – CBC with diff, TSH, Calcium
    
  • – Urine Toxicology
• Treatment:
  • Therapy
    • Cognitive behavioral therapy and Eye movement desensitization and reprocessing
  • Medication
    • SSRI
      • Fluoxetine (Prozac)
      • Paroxetine (Paxil, Paxil CR, Pexeva)
      • Sertraline (Zoloft)

Sleep Deprivation

• Presentation:
  • – feeling tired and sleepy during the day. Change work shifts
  • – Sleep deprivation is a general lack of the necessary amount of sleep.
  • – This may occur as a result of sleep disorders, active choice or deliberate inducement such as in interrogation or for torture.
• DDX:
  • – Sleep deprivation
    
  • – Sleep Apnea
    
  • – Depression
    
  • – Anemia
• Work-up:
  • – CBC with diff
    
  • – Nocturnal pulse oximetry
    
  • – Polysomnography
• Treatment:
  • Sleep Hygiene