ELDER TIP With age, vitamin B12 absorption may also diminish, resulting in reduced erythrocyte mass and decreased hemoglobin (Hb) levels and hematocrit (HCT).
Pernicious anemia primarily affects people of northern European ancestry. It’s rare in children and infants. Onset typically occurs after age 35, and incidence increases with age. It affects about 2% of people older than age 60.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Sickle cell anemia:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Sickle cell anemia results from homozygous inheritance of the gene that produces HbS (chromosome 11). It's inherited as an autosomal recessive trait. Heterozygous inheritance of this gene results in sickle cell trait, a condition that usually produces no symptoms. (See Sickle cell trait.) Sickle cell anemia is most common in tropical Africans and in people of African descent; about 1 in 10 American blacks carries the abnormal gene. However, sickle cell anemia also appears in other ethnic populations, including people of Mediterranean or East Indian ancestry.
If two parents who are both carriers of sickle cell trait (or another hemoglobinopathy) have offspring, each child has a 25% chance of developing sickle cell anemia. (See Inheritance patterns in sickle cell anemia, page 22.) Overall, 1 in every 400 to 600 black children has sickle cell anemia. The defective HbS-producing gene may have persisted because, in areas where malaria is endemic, the heterozygous sickle cell trait provides resistance to malaria and is actually beneficial.
The abnormal HbS found in such patients' RBCs become insoluble whenever hypoxia occurs. As a result, these RBCs become rigid, rough, and elongated, forming a crescent or sickle shape. (See Comparing normal and sickled red blood cells.) Such sickling can produce hemolysis (cell destruction). In addition, these altered cells tend to pile up in capillaries and smaller blood vessels, making blood more viscous. Normal circulation is impaired, causing pain, tissue infarctions, and swelling. Such blockage causes anoxic changes that lead to further sickling and obstruction.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Sideroblastic anemias:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Hereditary sideroblastic anemia appears to be transmitted by X-linked inheritance, occurring mostly in young males; females are carriers and usually show no signs of this disorder.
The acquired form may be secondary to ingestion of or exposure to toxins, such as alcohol and lead, or to certain drugs. It can also occur as a complication of other diseases, such as rheumatoid arthritis, lupus erythematosus, multiple myeloma, tuberculosis, and severe infections.
The primary acquired form, known as refractory anemia with ringed sideroblasts, is most common in elderly people. It’s commonly associated with thrombocytopenia or leukopenia as part of a myelodysplastic syndrome.
In sideroblastic anemia, normoblasts fail to use iron to synthesize Hb. As a result, iron is deposited in the mitochondria of normoblasts, which are then termed ringed sideroblasts.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Chronic fatigue syndrome:
Causes
(Professional Guide to Diseases (Eighth Edition))
The cause of chronic fatigue syndrome (CFS) is unknown, but researchers suspect that it may be found in human herpes virus-6 or in other herpesviruses, enteroviruses, or retroviruses. Recent studies have shown that inflammation of nervous system pathways, acting as an immune or autoimmune response, may play a role as well. CFS may also be associated with a reaction to viral illness that’s complicated by dysfunctional immune response and by other factors that may include gender, age, genetic disposition, prior illness, stress, and environment.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Congenital anomalies of the ureter, bladder, and urethra:
Causes
(Professional Guide to Diseases (Eighth Edition))
Congenital anomalies of the ureter, bladder, and urethra are among the most common birth defects, occurring in about 5% of all births. Their causes are unknown; diagnosis and treatment vary.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Fatigue:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
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.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Tunnel vision [Gun barrel vision, tubular vision]:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Glaucoma, chronic open-angle
Bilateral tunnel vision occurs late in this insidious disorder and slowly progresses to complete blindness. Other late findings include mild eye pain, halo vision, and reduced visual acuity (especially at night) that isn’t correctable with glasses.
Retinal pigmentary degeneration
This group of hereditary disorders, such as retinitis pigmentosa, produces an annular scotoma that progresses concentrically, causing tunnel vision and eventually complete blindness, usually by age 50. Impaired night vision, the earliest symptom, typically appears during the first or second decade of life. An ophthalmoscopic examination may reveal narrowed retinal blood vessels and a pale optic disk.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anemia:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Iron deficiency
❑ Chronic disease
❑ Vitamin B12 deficiency
❑ Subacute blood loss
❑ Thalassemia trait
❑ Folate deficiency
❑ Sickle cell trait
❑ Immune hemolytic anemia
❑ Myeloproliferative disease
❑ Aplastic anemia
❑ Sideroblastic anemia
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Source: Field Guide to Bedside Diagnosis, 2007
Fatigue:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Infectious mononucleosis
❑ Depression
❑ Diabetes
❑ Hypothyroidism
❑ Drugs
❑ Chronic sleep deprivation
❑ Congestive heart failure
❑ Occult infection
❑ Iron deficiency anemia
❑ Obstructive sleep apnea
❑ Renal failure
❑ Chronic fatigue syndrome
❑ Cushing syndrome
❑ Occult cancer
❑ Addison disease
❑ Myasthenia gravis
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Source: Field Guide to Bedside Diagnosis, 2007
Renal tubular acidosis:
Causes
(Handbook of Diseases)
Metabolic acidosis usually results from renal excretion of bicarbonate. However, metabolic acidosis associated with RTA results from a defect in the kidneys’normal tubular acidification of urine.
Distal RTA
Type I RTA results from an inability of the distal tubule to secrete hydrogen ions against established gradients across the tubular membrane. This results in decreased excretion of titratable acids and ammonium, increased loss of potassium and bicarbonate in the urine, and systemic acidosis.
Prolonged acidosis causes mobilization of calcium from bone and eventually hypercalciuria, predisposing the patient to the formation of renal calculi.
Distal RTA may be classified as primary or secondary:
❑ Primary distal RTA may occur sporadically or through a hereditary defect and is most prevalent in females, older children, adolescents, and young adults.
❑ Secondary distal RTA has been linked to many renal and systemic conditions, such as starvation, malnutrition, hepatic cirrhosis, and several genetically transmitted disorders.
Proximal RTA
Type II RTA results from defective reabsorption of bicarbonate in the proximal tubule. This causes bicarbonate to flood the distal tubule, which normally secretes hydrogen ions, and leads to impaired formation of titratable acids and ammonium for excretion. Ultimately, metabolic acidosis results.
Proximal RTA occurs in two forms:
❑ With primary proximal RTA, the reabsorptive defect is idiopathic and is the only disorder present.
❑ With secondary proximal RTA, the reabsorptive defect may be one of several defects and results from proximal tubular cell damage from a disease such as Fanconi’s syndrome.
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Source: Handbook of Diseases, 2003
Aplastic and hypoplastic anemias:
Causes
(Handbook of Diseases)
Aplastic anemias usually develop when damaged or destroyed stem cells inhibit red blood cell (RBC) production. Less commonly, they develop when damaged bone marrow microvasculature creates an unfavorable environment for cell growth and maturation. About half of such anemias result from drugs (antibiotics, anticonvulsants), toxic agents (such as benzene and chloramphenicol), or radiation. The rest may result from immunologic factors (unconfirmed), severe disease (especially hepatitis), or preleukemic and neoplastic infiltration of bone marrow. (See Understanding bone marrow transplantation.)
Idiopathic anemias may be congenital and account for about 50% of all confirmed occurrences. Two such forms of aplastic anemia have been identified: congenital hypoplastic anemia (Blackfan-Diamond anemia), which develops between ages 2 months and 3 months, and Fanconi’s syndrome, which develops between birth and age 10.
With Fanconi’s syndrome, chromosomal abnormalities are typically associated with multiple congenital anomalies — such as dwarfism and hypoplasia of the kidneys and spleen. In the absence of a consistent familial or genetic history of aplastic anemia, researchers suspect that these congenital abnormalities result from an induced change in the development of the fetus.
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Source: Handbook of Diseases, 2003
Chronic fatigue and immune dysfunction syndrome:
Causes
(Handbook of Diseases)
Although the cause of CFIDS is unknown, researchers suspect that it may be found in human herpesvirus 6 or in other herpesviruses, enteroviruses, or retroviruses. Rising levels of antibodies to EBV, once thought to implicate EBV infection as the cause of CFIDS, are now considered a result of this disease.
CFIDS may be associated with a reaction to viral illness that’s complicated by dysfunctional immune response and by other factors that may include sex, age, genetic disposition, prior illness, stress, and environment.
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Source: Handbook of Diseases, 2003
Folic acid deficiency anemia:
Causes
(Handbook of Diseases)
Folic acid deficiency anemia results from a decreased level or lack of folate, a vitamin that’s essential for red blood cell production and maturation. Causes include:
❑ alcohol abuse (may suppress metabolic effects of folate)
❑ inadequate diet (common in alcoholics, elderly people who live alone, and infants, especially those with infections or diarrhea)
❑ impaired absorption (due to intestinal dysfunction from such disorders as celiac disease, tropical sprue, and regional jejunitis and from bowel resection)
❑ bacteria competing for available folic acid
❑ overcooking, which can destroy a high percentage of folic acids in foods
❑ limited storage capacity in infants
❑ prolonged drug therapy (with anticonvulsants and estrogens)
❑ increased folic acid requirement during pregnancy, during rapid growth in infancy (common because of increased survival rate of preterm infants), during childhood and adolescence (because of general use of folate-poor cow’s milk), and in patients with neoplastic diseases and some skin diseases (chronic exfoliative dermatitis).
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Source: Handbook of Diseases, 2003
Iron deficiency anemia:
Causes
(Handbook of Diseases)
Iron deficiency anemia may result from:
❑ inadequate dietary intake of iron (less than 2 mg/day) — for example, during prolonged, unsupplemented periods of breast- or bottle-feeding (not eating solid foods after age 6 months) and during periods of stress, such as rapid growth in children and adolescents
❑ iron malabsorption, as in chronic diarrhea, partial or total gastrectomy, and malabsorption syndromes such as celiac disease
❑ blood loss secondary to drug-induced GI bleeding (from anticoagulants, aspirin, or steroids) or due to heavy menses, hemorrhage from trauma, a GI ulcer, cancer, or bleeding varices
❑ pregnancy, which diverts maternal iron to the fetus for erythropoiesis
❑ intravascular hemolysis-induced hemoglobinuria or paroxysmal nocturnal hemoglobinuria
❑ mechanical erythrocyte trauma caused by a prosthetic heart valve or vena cava filters.
Iron deficiency anemia is most common in premenopausal women, infants (particularly premature and low-birth-weight infants), children, and adolescents (especially girls).
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Source: Handbook of Diseases, 2003
Pernicious anemia:
Causes
(Handbook of Diseases)
Familial incidence of pernicious anemia suggests a genetic predisposition. A significantly higher incidence in patients with immunologically related diseases — such as thyroiditis, myxedema, and Graves’ disease — seems to support a widely held theory that an inherited autoimmune response causes gastric mucosal atrophy and, therefore, deficiency of hydrochloric acid and IF.
Deficiency of IF impairs absorption of vitamin B12. The resultant vitamin B12 deficiency inhibits cell growth, particularly of red blood cells (RBCs), leading to insufficient and deformed RBCs with poor oxygen-carrying capacity. Vitamin B12 deficiency also impairs myelin formation, causing neurologic damage. Iatrogenic induction of IF deficiency can follow partial gastrectomy.
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Source: Handbook of Diseases, 2003
Sickle cell anemia:
Causes
(Handbook of Diseases)
Sickle cell anemia results from homo-zygous inheritance of the Hb S gene, which causes substitution of the amino acid valine for glutamic acid in the B Hb chain. Heterozygous inheritance of this gene results in sickle cell trait, usually an asymptomatic condition. (See Sickle cell trait, page 774.)
Altered cells
The abnormal Hb S found in RBCs of patients with sickle cell anemia becomes insoluble whenever hypoxia occurs. As a result, these RBCs become rigid, rough, and elongated, forming a crescent, or sickle, shape. Such sickling can produce hemolysis (cell destruction).
In addition, these altered cells tend to pile up in capillaries and smaller blood vessels, making the blood more viscous. Normal circulation is impaired, causing pain, tissue infarctions, and swelling. Such blockage causes anoxic changes that lead to further sickling and obstruction.
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Source: Handbook of Diseases, 2003
Sideroblastic anemias:
Causes
(Handbook of Diseases)
Hereditary sideroblastic anemia appears to be transmitted by X-linked inheritance, occurring mostly in young males; females are carriers and usually show no signs of this disorder.
The acquired form may be secondary to ingestion of, or exposure to, toxins, such as alcohol and lead, or to drugs, such as isoniazid and chloramphenicol. It can also occur as a complication of other diseases, such as rheumatoid arthritis, lupus erythematosus, multiple myeloma, tuberculosis, and severe infections.
The primary acquired form, known as refractory anemia with ringed sideroblasts, is most common in elderly people. It’s often associated with thrombocytopenia or leukopenia as part of a myelodysplastic syndrome.
In sideroblastic anemia, normoblasts fail to use iron to synthesize Hb. As a result, iron is deposited in the mitochondria of normoblasts, which are then called ringed sideroblasts.
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Source: Handbook of Diseases, 2003
Fatigue:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Acquired immunodeficiency syndrome
In addition to fatigue, acquired immunodeficiency syndrome (AIDS) may cause fever, night sweats, weight loss, diarrhea, and a cough, followed by several concurrent opportunistic infections. The patient may also show signs of malnutrition.
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 listlessness, irritability, inability to concentrate, pallor, tachycardia, and dyspnea.
CULTURAL CUE:To detect anemia-related pallor in the dark-skinned patient, assess his oral mucosa.
Anxiety
Chronic, unremitting anxiety invariably produces fatigue, commonly 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, the cause of which is unknown, is characterized by incapacitating fatigue. Other findings are sore throat, myalgia, low-grade fever, painful lymph nodes, sleep disturbances, and cognitive dysfunction.
Chronic obstructive pulmonary disease
The earliest and most persistent symptoms of chronic obstructive pulmonary disease (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.
Cirrhosis
Severe fatigue typically occurs late in cirrhosis, accompanied by weight loss, bleeding tendencies, jaundice, hepatomegaly, ascites, dependent edema, severe pruritus, and decreased level of consciousness (LOC).
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 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, narrowed pulse pressure, 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.
Hypopituitarism
With 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 hypothyroidism, along with forgetfulness, cold intolerance, weight gain, metrorrhagia, and constipation. Related findings include coarse hair and alopecia; anorexia; edema; dry, flaky skin; and thinning nails.
Infection
With chronic infection (such as acute bacterial endocarditis), fatigue is commonly the most prominent symptom — and sometimes the only one. 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.
With acute infection, brief fatigue typically accompanies headache, anorexia, arthralgia, chills, high fever, and such infection-specific signs as cough, vomiting, or diarrhea.
Lyme disease
Besides fatigue and malaise, signs and symptoms of Lyme disease include intermittent headache, fever, chills, expanding red rash, and muscle and joint aches. In later stages of this tick-borne disease, 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.
Myocardial infarction
With myocardial infarction (MI), 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 narcolepsy: 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 and changes in personality and LOC, 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, 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 of restrictive lung disease: dyspnea, cough, and rapid, shallow respirations. Cyanosis first appears with exertion; later, even at rest.
Rheumatoid arthritis
With rheumatoid arthritis, fatigue, weakness, and anorexia precede localized articular findings: joint pain, tenderness, warmth, and swelling along with morning stiffness. Assessment findings may include enlarged lymph nodes, fever, leukopenia, anemia, subcutaneous nodules, pericarditis, and Raynaud’s phenomenon.
Systemic lupus erythematosus
Fatigue usually occurs in patients with systemic lupus erythematosus (SLE), 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
With thyrotoxicosis, fatigue may occur with 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
With carbon monoxide poisoning, fatigue occurs along with headache, dyspnea, and confusion, and can eventually progress to unconsciousness and apnea.
Drugs
Fatigue may result from various drugs, notably antihypertensives and sedatives. In persons receiving cardiac glycoside therapy, fatigue may indicate toxicity.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Fatigue:
Principal Causes of Fatigue
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Physiologiccauses
- Pathologic causes
- Anemia
- Infection
- Chronic disease
- Allergic disease
- Chronic fatigue syndrome
- Drugs
- Psychologic
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Pallor (Anemia):
Principal Causes of Pallor (Anemia)
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Disordersof decreased red cell or hemoglobin production
- Nutritionaldeficiencies
- Irondeficiency
- Folic acid deficiency
- Vitamin B12 deficiency
- Hypoplastic or aplastic anemias
- Pure redcell aplasia
- Congenitalhypoplastic anemia (Diamond-Blackfan anemia)
- Transient erythroblastopenia of childhood
- Anemia associated with systemic disease
- Drug-related
- Aplastic anemia
- Congenital
- Acquired
- Malignancy
- Abnormal heme and globin synthesis
- Thalassemias
- Alpha-thalassemias
- Beta-thalassemias
- Sideroblastic anemias
- Lead poisoning
- Disorders of increased red cell destruction(hemolytic anemias)
- Hemoglobinopathies
- Sickle cell disease
- Hemogloblin C disease
- Hemoglobin SC disease
- Hemoglobin E disease
- Unstable hemoglobins
- Red cell membrane defects
- Hereditaryspherocytosis
- Hereditary elliptocytosis
- Hereditary stomatocytosis
- Infantile pyknocytosis
- Paroxysmal nocturnal hemoglobinuria
- Red cell enzyme defects
- Glucose-6-phosphatedehydrogenase deficiency
- Pyruvate kinase deficiency
- Other
- Immune hemolytic anemias
- Isoimmunehemolytic anemia (Rh and ABO incompatibility)
- Autoimmune hemolytic anemia
- Red cell injury
- Thermal
- Mechanical
- Toxins
- Infection
- Copper toxicity
- Hypophosphatemia
- Blood loss
- Neonates
- Occult bleeding prior to birth
- Obstetric accidents
- Internal hemorrhage
- Excessive blood sampling
- Infants, children, and adolescents
- Trauma
- Severe epistaxis or hemoptysis
- Gastrointestinal bleeding
- Excessive menstrual bleeding
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fatigue:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
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 continue. 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. (See Managing the patient with myasthenia gravis.)
Renal failure.Acute renal failure commonly 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, vision disturbances, confusion, seizures, and coma.
Systemic lupus erythematosus (SLE).Fatigue usually occurs with SLE 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 with carbon monoxide poisoning 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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Tunnel vision [Gun barrel vision, tubular vision]:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Chronic open-angle glaucoma.With chronic open-angle glaucoma, bilateral tunnel vision occurs late and slowly progresses to complete blindness. Other late findings include mild eye pain, halo vision, and reduced visual acuity (especially at night) that isn't correctable with glasses.
Retinal pigmentary degeneration.Retinal pigmentary degeneration disorders, a group of hereditary disorders such as retinitis pigmentosa, produces an annular scotoma that progresses concentrically, causing tunnel vision and eventually resulting in complete blindness, usually by age 50. Impaired night vision, the earliest symptom, typically appears during the first or second decade of life. An ophthalmoscopic examination may reveal narrowed retinal blood vessels and a pale optic disk.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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