Tired All the Time

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Tired All the Time

• 21st November 2007

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(No Transcript)
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• Tiredness- can mean drowsiness, weakness, lack of
  energy, lack of motivation etc
• May be used as a legitimate symptom to consult
  the doctor for more awkward problems
• Very common presenting symptoms-numbers?

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An approach to tirednessHistory

• Clarifying symptoms-duration, time of day, sleep
  pattern
• Associated physical symptoms-weight changes, SOB,
  change in bowel habit, menorrhagia, polyuria,
  snoring etc
• Associated psychiatric symptoms-low mood,
  anxiety, sleep disturbance, changes in appetite
• Recent infections
• Medications
• Alcohol
• Employment and social history

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An approach to tirednessExamination

• Often entirely normal and unhelpful
• But reasonable to check for-
• -Weight
• -Pallor
• -Lymphadenopathy
• -Arrythmias
• -Hypothyroidism
• -Cardiac failure
• Also mental state examination-or at least
  screening questions for depression/ anxiety

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• Huge potential differential diagnosis for
  tiredness
• Brighton and Ram will look at some of the
  physical and psychological causes
• But first, a real life consultation
• (Cue Andys video!)

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TIRED ALL THE TIMEHELP ME DOC?
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TIRED ALL THE TIME

• Beware to classify the patients as heart sink
• Remember that there may be serious underlying
  disease.
• Take the patients seriously
• Be systematic and see this consultation as a
  challenge to your clinical skills rather than an
  imposition.

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TIRED ALL THE TIME
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TIRED ALL THE TIME

• Only 20 to 30 cases will have a discernible
  physical disease.
• Around 75 of cases are due to some form of
  psychological distress

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TIRED ALL THE TIMEORGANIC CAUSES

• Diabetes or Renal failurethirst, nocturia or
  polyuria
• Cardiac failure---fatigue
• Infections---bacterial, viral, GF, post viral,
  TB, HIV, Brucella, Endocarditis
• Iatrogenic beta blockers, antidepressants,
  tranquillisers
• Alcohol

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TIRED ALL THE TIMEORGANIC CAUSES

• Other endocrinehypothroid, addisons,
  hypopituitary
• Metabolic uraemia, liver failure
• Anaemia-consider a faulty diet (elderly)
• Myopathies e.g. myasthenia gravis
• Neuropathies e.g. motor neurone disease
• Malignancy

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TIRED ALL THE TIMEINVESTIGATIONS

• Urinalysisglucose and albumin (DM and Renal
  disease) also blood sugar.
• FBC anaemia (find the cause of anaemia)
• UE and cret renal problem or low K due to
  laxative abuse
• LFTs alcohol abuse
• ESR, CRP or monospot test
• TFTs
• Tumour markers
• Scans

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Physiological Causes

• After Physical activity
• Stress Exams, Work
• Sleep Deprivation
• Dieting or Anorexia
• Boredom

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Psychological Causes

• Depression
• Anxiety
• Bipolar Affective Disorder
• Somatisation
• Personality Disorder

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Assessment

• Low mood
• Anhedonia
• Biological Symptoms
• Diurnal Variation
• Recent illness

• Identifiable life event triggers
• Absence of physical signs
• HADS/PHQ-9
• Risk Assessment

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Management

• Counselling
• Anti-Depressants
• CBT
• Exclude physical cause

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Tips

• If absence of volunteered symptoms unlikely to
  have physical cause
• Longer it has been problem less likely to find
  remediable cause
• First impressions
• If depression suspected enquire directly
• Investigations often more therapeutic than
  diagnostic

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TIRED ALL THE TIMETHANK YOU!!