Diseases » Autoimmune Hemolytic Anemia

Fatigue

Fatigue: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Fatigue is a feeling of excessive tiredness, a lack of energy, or exhaustion accompanied by a strong desire to rest or sleep. This common symptom is distinct from weakness, which involves the muscles, but may occur with it.

Fatigue is a normal and important response to physical overexertion, prolonged emotional stress, and sleep deprivation. However, it can also be a nonspecific symptom of a psychological or physiologic disorder — especially viral or bacterial infection and endocrine, cardiovascular, or neurologic disease.

Fatigue reflects hypermetabolic and hypometabolic states in which nutrients needed for cellular energy and growth are lacking because of overly rapid depletion, impaired replacement mechanisms, insufficient hormone production, or inadequate nutrient intake or metabolism.

History and physical examination

Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.

Ask about related symptoms and recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and appetite or weight changes. Carefully review the patient’s medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.

Obtain a thorough drug history, noting the use of any drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk for carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector.

Observe the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.

Medical causes

Acquired immunodeficiency syndrome (AIDS)

In addition to fatigue, AIDS may cause a fever, night sweats, weight loss, diarrhea, and a cough, followed by several concurrent opportunistic infections.

Adrenocortical insufficiency

Mild fatigue, the hallmark of adrenocortical insufficiency, initially appears after exertion and stress, but later becomes more severe and persistent. Weakness and weight loss typically accompany GI disturbances, such as nausea, vomiting, anorexia, abdominal pain, and chronic diarrhea; hyperpigmentation; orthostatic hypotension; and a weak, irregular pulse.

Anemia

Fatigue following mild activity is commonly the first symptom of anemia. Associated findings vary, but generally include pallor, tachycardia, and dyspnea.

Anxiety

Chronic, unremitting anxiety invariably produces fatigue, typically characterized as nervous exhaustion. Other persistent findings include apprehension, indecisiveness, restlessness, insomnia, trembling, and increased muscle tension.

Cancer

Unexplained fatigue is commonly the earliest sign of cancer. Related findings reflect the type, location, and stage of the tumor and typically include pain, nausea, vomiting, anorexia, weight loss, abnormal bleeding, and a palpable mass.

Chronic fatigue syndrome

Chronic fatigue syndrome, whose cause is unknown, is characterized by incapacitating fatigue. Other findings are a sore throat, myalgia, and cognitive dysfunction. Diagnostic criteria have been determined, but research and data collection continues. These findings may alter the diagnostic criteria.

Chronic obstructive pulmonary disease (COPD)

The earliest and most persistent symptoms of COPD are progressive fatigue and dyspnea. The patient may also experience a chronic and usually productive cough, weight loss, barrel chest, cyanosis, slight dependent edema, and poor exercise tolerance.

Depression

Persistent fatigue unrelated to exertion nearly always accompanies chronic depression. Associated somatic complaints include a headache, anorexia (occasionally, increased appetite), constipation, and sexual dysfunction. The patient may also experience insomnia, slowed speech, agitation or bradykinesia, irritability, loss of concentration, feelings of worthlessness, and persistent thoughts of death.

Diabetes mellitus

Fatigue, the most common symptom in diabetes mellitus, may begin insidiously or abruptly. Related findings include weight loss, blurred vision, polyuria, polydipsia, and polyphagia.

Heart failure

Persistent fatigue and lethargy characterize heart failure. Left-sided heart failure produces exertional and paroxysmal nocturnal dyspnea, orthopnea, and tachycardia. Right-sided heart failure produces jugular vein distention and, possibly, a slight but persistent nonproductive cough. In both types, mental status changes accompany later signs and symptoms, including nausea, anorexia, weight gain and, possibly, oliguria. Cardiopulmonary findings include tachypnea, inspiratory crackles, palpitations and chest tightness, hypotension, a narrowed pulse pressure, a ventricular gallop, pallor, diaphoresis, clubbing, and dependent edema.

Hypercortisolism

Hypercortisolism typically causes fatigue, related in part to accompanying sleep disturbances. Unmistakable signs include truncal obesity with slender extremities, buffalo hump, moon face, purple striae, acne, and hirsutism; increased blood pressure and muscle weakness are other findings.

Hypothyroidism

Fatigue occurs early in hypothyroidism, along with forgetfulness, cold intolerance, weight gain, metrorrhagia, and constipation.

Infection.

With chronic infection, fatigue is commonly the most prominent symptom — and sometimes the only one. A low-grade fever and weight loss may accompany signs and symptoms that reflect the type and location of infection, such as burning upon urination or swollen, painful gums. Subacute bacterial endocarditis is an example of a chronic infection that causes fatigue and acute hemodynamic decompensation

With acute infection, brief fatigue typically accompanies a headache, anorexia, arthralgia, chills, a high fever, and such infection-specific signs as a cough, vomiting, or diarrhea.

Lyme disease

In addition to fatigue and malaise, signs and symptoms of Lyme disease include an intermittent headache, a fever, chills, an expanding red rash, and muscle and joint aches. In later stages, patients may suffer arthritis, fluctuating meningoencephalitis, and cardiac abnormalities, such as a brief, fluctuating atrioventricular heart block

Malnutrition

Easy fatigability is common in patients with protein-calorie malnutrition, along with lethargy and apathy. Patients may also exhibit weight loss, muscle wasting, sensations of coldness, pallor, edema, and dry, flaky skin

Myasthenia gravis

The cardinal symptoms of myasthenia gravis are easy fatigability and muscle weakness, which worsen as the day progresses. They also worsen with exertion and abate with rest. Related findings depend on the specific muscles affected

Renal failure

Acute renal failurecommonly causes sudden fatigue, drowsiness, and lethargy. Oliguria, an early sign, is followed by severe systemic effects: an ammonia breath odor, nausea, vomiting, diarrhea or constipation, and dry skin and mucous membranes. Neurologic findings include muscle twitching and changes in the patient’s personality and level of consciousness, possibly progressing to seizures and coma.

With chronic renal failure, insidious fatigue and lethargy occur with marked changes in all body systems, including GI disturbances, an ammonia breath odor, Kussmaul’s respirations, bleeding tendencies, poor skin turgor, severe pruritus, paresthesia, visual disturbances, confusion, seizures, and coma.

Systemic lupus erythematosus

Fatigue usually occurs along with generalized aching, malaise, a low-grade fever, a headache, and irritability. Primary signs and symptoms include joint pain and stiffness, a butterfly rash, and photosensitivity. Also common are Raynaud’s phenomenon, patchy alopecia, and mucous membrane ulcers.

Valvular heart disease.

All types of valvular heart disease commonly produce progressive fatigue and a cardiac murmur. Additional signs and symptoms vary, but generally include exertional dyspnea, a cough, and hemoptysis

Other causes

Carbon monoxide poisoning

Fatigue occurs along with a headache, dyspnea, and confusion and can eventually progress to unconsciousness and apnea.

Drugs

Fatigue may result from various drugs, notably antihypertensives and sedatives. In those receiving cardiac glycoside therapy, fatigue may indicate toxicity.

Surgery

Most types of surgery cause temporary fatigue, probably due to the combined effects of hunger, anesthesia, and sleep deprivation.

Special considerations

If fatigue results from organic illness, help the patient determine which daily activities he may need help with and how he should pace himself to ensure sufficient rest. You can help him reduce chronic fatigue by alleviating pain, which may interfere with rest, or nausea, which may lead to malnutrition. He may benefit from referral to a community health nurse or housekeeping service. If fatigue results from a psychogenic cause, refer him for psychological counseling.

Pediatric pointers

When evaluating a child for fatigue, ask his parents if they’ve noticed a change in his activity level. Fatigue without an organic cause occurs normally during accelerated growth phases in preschool-age and prepubescent children. However, psychological causes of fatigue must be considered — for example, a depressed child may try to escape problems at home or school by taking refuge in sleep. In the pubescent child, consider the possibility of drug abuse, particularly of hypnotics and tranquilizers.

Geriatric pointers

Always ask older patients about fatigue because this symptom may be insidious and mask more serious underlying conditions in this age-group. Temporal arthritis, which is much more common in people older than age 60, is usually characterized by fatigue, weight loss, jaw claudication, proximal muscle weakness, a headache, vision disturbances, and associated anemia.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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