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Tired All the Time

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Tired All the Time

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    1. Tired All the Time 21st November 2007

    3. 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?

    4. An approach to tiredness: History 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

    5. An approach to tiredness: Examination 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

    6. 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 Andy’s video!)

    7. TIRED ALL THE TIME HELP ME DOC?

    8. 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.

    9. TIRED ALL THE TIME

    10. 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

    11. TIRED ALL THE TIME ORGANIC CAUSES Diabetes or Renal failure—thirst, nocturia or polyuria Cardiac failure---fatigue Infections---bacterial, viral, GF, post viral, TB, HIV, Brucella, Endocarditis Iatrogenic –beta blockers, antidepressants, tranquillisers Alcohol

    12. TIRED ALL THE TIME ORGANIC CAUSES Other endocrine—hypothroid, addison’s, hypopituitary Metabolic –uraemia, liver failure Anaemia-consider a faulty diet (elderly) Myopathies e.g. myasthenia gravis Neuropathies e.g. motor neurone disease Malignancy

    13. TIRED ALL THE TIME INVESTIGATIONS Urinalysis—glucose and albumin (DM and Renal disease) also blood sugar. FBC –anaemia (find the cause of anaemia) U&E and cret –renal problem or low K due to laxative abuse LFTs – alcohol abuse ESR, CRP or monospot test TFTs Tumour markers Scans

    14. Physiological Causes After Physical activity Stress – Exams, Work Sleep Deprivation Dieting or Anorexia Boredom

    15. Psychological Causes Depression Anxiety Bipolar Affective Disorder Somatisation Personality Disorder

    16. Assessment Low mood Anhedonia Biological Symptoms Diurnal Variation Recent illness Identifiable life event triggers Absence of physical signs HADS/PHQ-9 Risk Assessment

    17. Management Counselling Anti-Depressants CBT Exclude physical cause

    18. 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

    19. TIRED ALL THE TIME THANK YOU!!

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