PD E2- General symptoms

What is a tired feeling and a sense of weariness that may or may not be related to or worsened by task performance?

Fatigue

What is a feeling that consists of listlessness & languor, a desire to sit and dream, perhaps even laziness or mental inertia?

Lassitude

What is a feeling of not being well, of being sick and out of sorts?

Malaise

What is a lack of motor strength and decreased ability to perform physical tasks, may be generalized or limited to specific muscle groups?

Weakness

What are precipitating factors to depression?

Marriage, divorce, parenthood, death of spouse, loss of job, other severe emotional stress

What population is fatigue more common in?

Women

What is acute fatigue?

< 1 mo; may follow infx (mono), prolonged exerting activity or poor sleep

What is the time frame for chronic fatigue or fibromyalgia?

> 1 mo

How does fatigue d/t organic disease present?

Less severe on awakening, worsens during the day, continuous & progressive

How does fatigue d/t psychiatric illness present?

Present equally on awakening & other times, does not worsen as day progresses, not relieved by rest, intermittent or remittent over time, & may improve on weekends or vacation

What medications can cause fatigue?

Antihistamines, sedatives, hypnotics, psychotropics, antihypertensives (B adrenergic blockers), methyldopa

What is a complex long term illness that causes extreme fatigue not relieved by rest, along with other sx such as sleep disturbance, HA, sore throat, and muscle or joint pain?

Chronic fatigue syndrome (CFS) aka myalgic encephalomyelitis

What are possible medical causes of chronic fatigue?

Chronic infx, malignancy, anemia, HF, hypothyroidism, certain drugs, sleep apnea, autoimmune, post viral fatigue (covid, flu, mono), psychiatric disease, fibromyalgia

If a patient presents with chronic fatigue, what other signs would point to malignancy?

Unexplained wt loss or hx of cancer

If a patient presents with chronic fatigue, what other signs would point anemia?

Signs of bleeding, heavy menses, or hemoccult positive

If a patient presents with chronic fatigue, what other signs would point heart failure?

difficulty breathing

If a patient presents with chronic fatigue, what other signs would point to hypothyroidism?

Wt gain, dry skin, hair loss, constipation, difficulty sleeping

What is the major criteria for CFS?

New onset persistent or relapsing debilitating faituge in person w/o hx of similar sx that does not resolve w/ bedrest & dec daily activity by > 50% for > 6 mos

Other conditions r/o

What are the minor symptom criteria for CFS?

Mild fever or chills, sore throat, painful cervical or axillary nodes, unexplained generalized weakness, muscle discomfort/myalgia, generalized HAs, > 24 hrs of fatigue after exercises previously tolerated, migratory arthralgias w/o arthritis, neuropsych sx, & hyper insomnia or insomnia

How much of the criteria must be met to dx CFS?

2 major criteria & 6 out of 11 minor symptom criteria w/ 2 out of 3 physical criteria

What does the frequent onset of viral infection, followed by fatigue, depression or other psychiatric illness suggest?

Immunologic dysfunction

What is a clinically apparent increase in the interstitial fluid volume, which may expand by several liters before abnormality is evident (can be localized or generalize)?

Edema

What condition is the accumulation of excess fluid in the peritoneal cavity?

Ascites

What is the accumulation of excess fluid in the pleural cavity?

Hydrothorax

What is gross, generalized edema?

Anasarca

What contributes to the pathogenesis of edema?

Starling forces, capillary damage due to trauma, reduction of effective arterial volume (retention of salt and water), reduced CO, & renal factors

What are possible clinical causes of edema?

Obstruction of venous & lymphatic drainage of a limb, CHF, nephrotic syndrome & other hypoalbuminemic states, cirrhosis, idiopathic

What might U/L edema be associated with?

Thrombophlebitis (recent surgery, previous phlebitis, prolonged inactivity, recent injury, redness, tenderness, fever, pain)

What might B/L edema be associated with?

DOE, orthopnea, ascites, jaundice, proteinuria, etc

What might acute facial swelling be due to?

Allergic reaction

What might chronic facial swelling be due to?

Hypoalbuminemia

What symptoms would be seen with general edema due to HF?

Cardiac enlargement, gallop, rales

What other indicators would be seen with general edema due to nephrotic syndrome?

Proteinuria > 3.5 g/dl, hypoalbuminemia < 2 g/dl, ± hypercholesterolemia

What other indicators would be associated with general edema due to acute GN or renal failure?

Hematuria, proteinuria, HTN

What else would be seen with general edema due to cirrhosis?

Ascites, jaundice, spider angiomas, hypoalbuminemia

What nutritional deficiency can cause general edema?

Protein deficiency

What are some meds that can cause general edema?

Estrogens, vasodilators, calcium antagonist (nifedipine)

When occurs with hypoalbuminemia when serum albumin < 2.5g/100 ml?

Dec oncotic pressure (DOP) → B/L pitting LE edema with facial/eyelid edema upon awakening

What occurs with increased hydrostatic pressure (IHP)?

Excessive fluid retention (CHF) → B/L LE edema

Impaired venous flow (venous insufficiency) → U/L LE edema ± varicosities

What occurs with increased capillary permeability (ICP)?

LE edema → d/t immunologic injury, infx, inflammation, trauma, or idiopathic

How does a DVT present?

U/L edema w/ calf tenderness, palpable cord, positive homans sign

(inc risk if paresis in one leg d/t stroke)

What can lymphatic obstruction cause?

Hindered reabsorption of interstitial fluid → swelling starts in feet & moves upward → U/L “brawny” edema w/ minimal pitting

*elevation provides minor relief

U/L vs B/L edema causes

What should be ordered for DVT?

Venogram (gold standard) & doppler US

What should be ordered for generalized B/L edema?

CXR (r/o CHF), UA (r/o proteinuria), BUN/Cr (r/o renal insufficiency) & serum albumin

if album low → PT/INR/PTT & LFTs (r/o hepatocellular failure)

if albumin low w/ protein in urine → 24 hr urine for albumin & cr (r/o kidney dz)

What patient education should be given for edema?

IHP or DOP → Salt restriction, d/c salt retaining drugs, avoid prolonged sitting/standing w/ LE dependency, avoid restrictive leg attire (garters)

ICP → above + propranolol or captopril

What drugs can cause weight loss?

Digitalis, quinidine, amphetamines, NSAIDs, antitumor agents

What should be done for a patient with unexplained weight loss who is low risk and normal H&P?

Observe for 1 month, no immediate labs, give nutritional advice, f/u in 4 weeks with food diary and weight log

What labs should be ordered for weight loss due to decreased intake?

CBC w/ diff, CMP, serum drug levels (digitalis), EGD or GI series in elderly, HIV

What labs should be ordered for weight loss due to impaired absorption?

Microscopic / guaiac stool, qual 72 hr stool fat, serum carotene, D-xylose test, secretin stimulation test, small bowel bx, O&P

What condition might be the cause of unexplained weight loss in an elderly/diabetic patient along with unexplained afib?

Apathetic hyperthyroidism (get TSH level)

What should be ordered for a febrile HIV patient with unexplained weight loss?

Acid fast bacillus smear (AFB) for TB and CMV

What is the MCC of steatorrhea in a patient with unexplained weight loss?

Pancreatic cancer (get US or CT)

What condition is associated with weight loss d/t increased nutrient loss with diarrhea, polyuria & polydipsia?

Diabetic enteropathy

What conditions can cause weight loss due to excess demand (metabolic)?

Hyperthyroidism, fever, malignancy, emotional stress (mania), amphetamine abuse

What conditions can cause weight loss due to increased nutrient loss?

Uncontrolled DM, persistent diarrhea, recurrent committing, fistulous tract drainage

What conditions can cause weight loss due to impaired absorption?

Alcoholism, viral hepatitis, uremia, malignancy, anorexia, poverty, dementia, crohns, UC

What conditions can cause weight loss due to decreased intake?

HIV/AIDs, depression, anxiety, poor dentition, esophageal/GI disease, drugs