Dr. Stevent Sumantri Sp.

PD

Dr. Stevent Sumantri Sp.PD-2015

• Describe etiologies of fatigue
• Recognize symptoms of fatigue
• Determine diagnosis causes of fatigue

Dr. Stevent Sumantri Sp.PD-2015

• Fatigue is common:
– Prevalence in in Britain and the US between 6.0 and 7.5%.
– Around 21-33% patients in primary care settings report
significant fatigue.
• Clinical fatigue:
– Inability to initiate activity;
– Reduced capacity to maintain activity; and
– Difficulty with concentration, memory, and emotional stability.
– Different from somnolence, dyspnea, and muscle weakness à
may also be associated with fatigue.

Dr. Stevent Sumantri Sp.PD-2015

In primary care: 6.5% chief complaint and up to 19% as part of other
complaints.*

Recent
Prolonged /
Chronic

• Medical or psychiatric: 2/3 of patients with chronic fatigue (>6 months)

• Psychiatric illness: 60 to 80 percent of patients with chronic fatigue

*IMAJ 2012; 14: 555-559

Dr. Stevent Sumantri Sp.PD-2015
Dr. Stevent Sumantri Sp.PD-2015
Dr. Stevent Sumantri Sp.PD-2015
• A specific etiology for fatigue is found less frequently when fatigue itself
is the principal concern.
• Based upon the duration of symptoms:
– Recent fatigue: symptoms < one month.
– Prolonged fatigue: symptoms one – six months.
– Chronic fatigue: symptoms > six months, does not necessarily chronic fatigue
syndrome.
• Component of History:
– Onset - abrupt or gradual, related to event or illness?
– Course - stable, improving or worsening?
– Duration and daily pattern
– Factors that alleviate or exacerbate symptoms
– Impact on daily life - ability to work, socialize, participate in family activities
– Accommodations that patient/family has made to adjust to fatigue symptoms
• Clinical Clues: Patients with fatigue that is not organ-based are tired all
the time.

Dr. Stevent Sumantri Sp.PD-2015

• Physical examination is important to exclude some specific causes of
fatigue
– General appearance: alertness, psychomotor agitation or retardation, grooming
– Lymphadenopathy
– Evidence of thyroid disease
– Cardiopulmonary examination
– Neurologic examination
• Extensive laboratory evaluation in the absence of a positive history or
physical examination are of little diagnostic utility
– Complete blood count with differential
– Erythrocyte sedimentation rate, ferritin
– Chemistry screen (including electrolytes, glucose, renal and liver function tests)
– Thyroid stimulating hormone
– Creatine kinase, if pain or muscle weakness present
– HIV testing and PPD placement if high risk

Dr. Stevent Sumantri Sp.PD-2015

• Rate of positive results is low

• The majority of the results à DO

NOT change management AND
only minority treated (<10%)**

• Eighty patients (26.8%)*

• Anemia (n=27),
• Vitamin B12 deficiency (n=8),
• Infectious disease (n=19),
• Pregnancy (n=8), and
• Psychiatric diagnosis (n=5).

*IMAJ 2012; 14: 555-559

**Ann Fam Med 2008;6:519-527
Dr. Stevent Sumantri Sp.PD-2015
• Uncommon cause of chronic fatigue symptoms (1-9%)
• Definition
– Clinically evaluated, unexplained, persistent or relapsing fatigue plus
four or more specifically defined associated symptoms
• Self-reported impairment in short term memory or concentration
• Sore throat
• Tender cervical or axillary nodes
• Muscle pain
• Multijoint pain without redness or swelling
• Headaches of a new pattern or severity
• Unrefreshing sleep
• Post-exertional malaise lasting ≥24 hours
• Idiopathic Chronic Fatigue à much common, not met the CFS
criteria, may be part of continuum

Dr. Stevent Sumantri Sp.PD-2015

• If specific disease found à treat accordingly to the underlying
disease.

• Idiopathic chronic fatigue or CFS should be managed in the same

fashion:
– The doctor-patient relationship is of profound importance.
– A trial of antidepressant drugs should be offered to patients whose illness has
features of depression.
– Cognitive behavioral therapy is effective à involves a series of one-hour sessions
to alter beliefs and behaviors.
– Graded exercise therapy (GET) is based on a physiological model of deconditioning.
– Reported rates of observed improvement with GET are approximately 55 percent,
compared to 70 percent for CBT.

Dr. Stevent Sumantri Sp.PD-2015

• CFS and idiopathic chronic fatigue are not generally favorable for full
return to premorbid status.
• Neither CFS nor idiopathic chronic fatigue results in organ failure or
death.
• Four prognostic groups:
– Ongoing continuous high fatigue scores (25%),
– Slow recovery (25%),
– Fast recovery (20%), and
– Initial improvement with recurrence (30%).
• Risk factors for poor prognosis:
– Older age,
– More chronic illness,
– Comorbid psychiatric disorder, and
– Firm belief that physical causes were responsible for the fatigue

Dr. Stevent Sumantri Sp.PD-2015

• Fatigue is common and debilitating
• Should be acknowledge as something real
• Most of them will have explainable causes
• Idiopathic and Chronic Fatigue syndrome is less
common
• Treat accordingly to the underlying cause
• CBT and GET is the mainstay management
• The prognosis is not favorable

Dr. Stevent Sumantri Sp.PD-2015

Dr. Stevent Sumantri Sp.PD-2015