Fatigue

Fatigue: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Fatigue is a feeling of excessive tiredness, 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 accompany 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 both 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 findings associated with psychological disorders.

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

Obtain a thorough drug history, noting use of any narcotic or drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk of carbon monoxide poisoning, and ask 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

Besides fatigue, this syndrome may cause fever, night sweats, weight loss, diarrhea, and a cough, followed by several concurrent opportunistic infections.

Adrenocortical insufficiency

Mild fatigue, the hallmark of this disorder, 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 after 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, often 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

This syndrome, whose cause is unknown, is characterized by incapacitating fatigue. Other findings are sore throat, myalgia, and cognitive dysfunction.

Chronic obstructive pulmonary disease

The earliest and most persistent symptoms of this disease 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.

Cirrhosis

Severe fatigue typically occurs late in this disorder, accompanied by weight loss, bleeding tendencies, jaundice, hepatomegaly, ascites, dependent edema, severe pruritus, and decreased level of consciousness.

Cushing’s syndrome (hypercortisolism)

This disorder typically causes fatigue, related in part to accompanying sleep disturbances. Cardinal signs include truncal obesity with slender extremities, buffalo hump, moon face, purple striae, acne, and hirsutism; increased blood pressure and muscle weakness may also occur.

Depression

Persistent fatigue unrelated to exertion nearly always accompanies chronic depression. Associated somatic complaints include 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 of this disorder, may begin insidiously or abruptly. Related findings include weight loss, blurred vision, polyuria, polydipsia, and polyphagia.

Heart failure

Persistent fatigue and lethargy characterize this disorder. 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, later signs and symptoms include mental status changes, nausea, anorexia, weight gain and, possibly, oliguria. Cardiopulmonary findings include tachypnea, inspiratory crackles, palpitations and chest tightness, hypotension, narrowed pulse pressure, ventricular gallop, pallor, diaphoresis, clubbing, and dependent edema.

Hypopituitarism

Fatigue, lethargy, and weakness usually develop slowly. Other insidious effects may include irritability, anorexia, amenorrhea or impotence, decreased libido, hypotension, dizziness, headache, visual disturbances, and cold intolerance.

Hypothyroidism

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

Infection

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

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

Lyme disease

Besides fatigue and malaise, signs and symptoms of this tick-borne disease include intermittent headache, fever, chills, an expanding red rash, and muscle and joint aches. Later, patients may develop arthritis, fluctuating meningoencephalitis, and cardiac abnormalities, such as a brief, fluctuating atrioventricular heart block.

Malnutrition

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

Myasthenia gravis

The cardinal symptoms of this disorder 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.

Myocardial infarction

Fatigue can be severe but is typically overshadowed by chest pain. Related findings include dyspnea, anxiety, pallor, cold sweats, increased or decreased blood pressure, and abnormal heart sounds.

Narcolepsy

One or more of the following characterizes this disorder: hypersomnia, hypnagogic hallucinations, cataplexy, sleep paralysis, and insomnia. Fatigue is a common symptom as well.

Renal failure

Acute renal failure commonly causes sudden fatigue, drowsiness, and lethargy. Oliguria, an early sign, is followed by severe systemic effects: ammonia breath odor, nausea, vomiting, diarrhea or constipation, and dry skin and mucous membranes. Neurologic findings include muscle twitching, personality changes, and altered level of consciousness, which may progress to seizures and coma.

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

Restrictive lung disease

Chronic fatigue may accompany the characteristic signs and symptoms: dyspnea, cough, and rapid, shallow respirations. Cyanosis first appears with exertion; later, even at rest.

Rheumatoid arthritis

Fatigue, weakness, and anorexia precede localized articular findings: joint pain, tenderness, warmth, and swelling along with morning stiffness.

Systemic lupus erythematosus

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

Thyrotoxicosis

In this disorder, fatigue may accompany characteristic signs and symptoms, including an enlarged thyroid, tachycardia and palpitations, tremors, weight loss despite increased appetite, diarrhea, dyspnea, nervousness, diaphoresis, heat intolerance, amenorrhea and, possibly, exophthalmos.

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, cough, and hemoptysis.

Other causes

Carbon monoxide poisoning

Fatigue occurs along with headache, dyspnea, and confusion; apnea and unconsciousness may occur eventually.

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 from 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 any 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, headache, visual disturbances, and associated anemia.

Patient counseling

Regardless of the cause of fatigue, you may need to help the patient alter his lifestyle to achieve a balanced diet, a program of regular exercise, and adequate rest. Counsel him about setting priorities, keeping a reasonable schedule, and developing good sleep habits. Teach stress management techniques as appropriate.

Book Source Details

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

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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