TIREDNESS, LETHARGY, FATIGUE
Allan is a 45 year old accountant who works in a large city bank. He has been feeling very tired for several weeks and was finding it difficult to manage at work." I don't know what's wrong with me," he said. " For the last month or so I've been absolutely exhausted. Some mornings I can hardly get out of bed."
We went through a careful history and there was nothing to go on. His appetite was fine and there had been no fevers, sweats or weight loss. Aside from a viral illness several weeks earlier, he had been in excellent health. Apparently things were going really well at work and at home. A full examination was completely normal. I tested his urine and this was also clear. Allan was so concerned about his symptoms that we felt some basic investigations were required. Several blood tests and a chest X-ray were arranged and a review appointment was made for later that week.
All his tests were clear. In particular there were no signs of anaemia or glandular fever and his thyroid function was normal. " Well I still feel pretty stuffed, " said Allan. " Someone at work said I've probably got chronic fatigue syndrome." I explained that there was no definite evidence of chronic fatigue syndrome and that it was too early to diagnose anyway. Although we were not able to put a precise label on his condition, Allan could at least be reassured that most of the more significant causes had been excluded. We discussed how tiredness can follow viral illness and how it just improves without any specific treatment. We also talked about exercise, diet and general ways of improving fitness. I asked Allan to give me a call in a couple of weeks to let me know how he was going. It was understood that if his symptoms were not much better we would arrange for him to see one of our specialist physicians.
Interestingly, Allan phoned me the following week to say that he was beginning to feel a little better. He said that he would call back to see me in a couple of weeks if he had not fully recovered.
Most GP's would probably see a couple of patients each day who complain of chronic tiredness and fatigue. The lethargy can be quite overwhelming and people are often frustrated by the persistence of their symptoms. Although very few turn out to have any serious underlying health problem, each case needs to be carefully assessed. The very non-specific nature of the symptoms is the main challenge for the doctor. It is true that psychological factors can cause lethargy and tiredness, and these may need treatment in their own right. However, it is always better to assume there is a physical explanation and exclude that first.
Some of the more common causes are:- * Post-viral / post-flu tiredness. * Other infections like glandular fever. * Anaemia from any cause, for instance a 40 year old woman with longstanding heavy menstrual loss. * Other medical conditions like diabetes, heart disease, and underactive thyroid gland. * Side-effects of certain medications, such as some blood pressure tablets and antihistamines. * Some chronic or ongoing illnesses, such as rheumatoid disease. Very uncommonly, the fatigue may be due to an underlying condition like cancer or lymphoma.
We are then left with a "cause not clear" group. Anxiety and depression may be major factors in this group. Chronic fatigue syndrome, or CFS, deserves a special mention.
It is characterized by debilitating long-term fatigue and may follow a flu-like illness. Nowadays there are specific diagnostic criteria that must be fulfilled. These include symptoms of at least six months duration, presence of a mild fever, palpable lymph-nodes, and the exclusion of other medical conditions.
CFS has gained clearer recognition in recent years. Extensive research continues into the actual cause of CFS, in particular the precise immunological aspects of the conditions. It is real, not imaginary, and one day we will know a lot more about it. weblink: http://www.cdc.gov/ncidod/diseases/cfs/facts.htm
When a patient complains of chronic tiredness, the doctor follows certain steps to sort out the problem. A very clear history is so important. What are the main symptoms and how long have they been present? Have there been any other symptoms, like fever, muscle weakness or loss of appetite? A careful physical examination is next, looking for signs of weight loss, anaemia or any other abnormalities. The urine is also checked for sugar.
Tests and investigations may or may not be required initially. Sometimes a basic blood test and chest X-ray are organized. A review of the patient a week or two after the first consultation is helpful. If things are not improving, further investigations or referral to a specialist may be necessary.
The treatment of chronic tiredness clearly depends on the cause; any underlying condition will require treatment. If no obvious cause for the symptoms is found, explanation and reassurance often helps a great deal, always with the option for further review or specialist referral. Attention to lifestyle factors is also worthwhile, with emphasis on rest, diet and a graded exercise program. If stress appears to be a factor, counselling and relaxation therapy may also be of use.
Occasionally a standard multi- vitamin preparation can help but large doses of vitamins and other supplements are not of any proven benefit. Alternative approaches like acupuncture can also be tried.
Health tips:
* With chronic lethargy and tiredness, the best place to start is a check-up with your
doctor. Because of the complex nature of the problem it is better to book a longer
consultation, and bring along a urine specimen as part of the examination.
* If you find that despite following your doctor's advice you are not improving as
expected, call back for a follow- up appointment.
Dr. Andrew Pattison: Common Consultations
North
East Valley Division General Practice,
Melbourne, Australia. Disclaimer
- Last modified: August 18, 2001