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Chapter 14 • Earache 181
https://t.me/med1917
variable frequency and intensity settings to test each ear
separately. The goal of audiometry is to test the lowest
decibel intensity that can be heard for each frequency
tested. An individual trained in the proper technique
will produce reliable, reproducible, and valid test
results. A threshold of up to 20 dB is considered normal. At a higher level, hearing loss is graded as mild,
moderate, moderately severe, severe, or profound.
Mastoid Process Radiography
Radiographs of the mastoid bone show clouding of the
air cells when otitis media is present. Chronic mastoiditis may reveal decalcication of the bony wall between
the mastoid air cells.
Computed Tomography Scanning
A computed tomography (CT) scan of the temporal bone
is helpful in diagnosing cholesteatoma and congenital
syndromes.
DIFFERENTIAL DIAGNOSIS
External Otitis
External otitis is more common in adults than in children
and often presents as bilateral pain that worsens with
manipulation of the pinna. The patient reports a stuffed
ear, and occasionally conductive hearing loss occurs.
Discharge and itching that occur 1 to 2 days after swimming may be associated with otitis externa. The affected
canal may be swollen shut. Palpation will often disclose
enlarged preauricular or postauricular nodes.
Acute Otitis Media
AOM most often occurs in children younger than 6 years
and is associated with an upper respiratory tract infection. It is an acute infection associated with ear pain and
a bulging, red eardrum. The pain of otitis media is severe
enough to interfere with sleep and may be suddenly
relieved if the eardrum perforates. Swelling of the preauricular node is sometimes seen in children with AOM.
Otitis Media with Effusion
Otitis media with effusion commonly occurs in children
and is by denition painless. It is caused by a mechanical
process or eustachian tube blockage that leads to inadequate ventilation of the middle ear. On exam, a collection
of uid that resembles mucus, air bubbles, or a uid level
is seen. Associated conductive hearing loss is usually
present. The TM may be injected and immobile, either
bulging or retracted, as noted by the shape of the cone of
light reex and pneumatic otoscopy. Associated recent
upper respiratory tract infection is a common nding in
adults.
Cholesteatoma
Cholesteatoma is an epidermal inclusion cyst formation
in the middle ear and mastoid cavity. It is often the sequel
of chronic otitis media. The formation occurs with
chronic negative middle ear pressure, causing the migration of skin cells from the external ear canal through a
perforation in the TM. Once established in the middle
ear, the cells desquamate and form the cholesteatoma.
This condition is life threatening if left untreated because
it will continue to erode away medially to impinge on
intracranial structures. A cholesteatoma can also occur
congenitally. A cholesteatoma appears as a cyst or collection of granulation tissue on the TM, commonly located
in the pars accida area in the superior anterior quadrant
of the TM.
Mastoiditis
Mastoiditis is an infection of the soft tissue surrounding the air spaces in the mastoid bone and is connected
to the middle ear space. Mastoiditis usually occurs
with bacterial otitis media and is associated with fever.
More advanced mastoiditis is manifested by swelling,
erythema, and tenderness over the mastoid bone.
Swelling can displace the position of the auricle. The
swelling can extend to the facial nerve, causing paralysis, or to the labyrinth or cerebrospinal uid, causing
meningitis or brain abscess. Advanced mastoiditis
requires immediate referral and surgical management.
Foreign Bodies
Foreign bodies are easily visualized on examination of
the ear canal and can produce foul-smelling ear drainage
secondary to infection or abscess.
Cerumen Impaction
Impaction of cerumen is likely if the patient reports a
stuffed-up ear or decreased hearing acuity. An impaction
may also produce pain if cerumen is pressed against the
TM. Examination will reveal cerumen that occludes the
external canal.
Barotrauma
Barotrauma produces an acute serous otitis that is caused
by pressure changes (e.g., in divers or airplane travelers)
and is often aggravated by a recent upper respiratory tract
182 Chapter 14 • Earache
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infection or nasal congestion. Serosanguineous uid collects in the middle ear; during descent this may be felt as
ear pressure, pain, tinnitus, or temporary deafness. Swallowing, chewing, or blowing out the nose with the mouth
and nose occluded can relieve symptoms.
Trauma
Blunt or penetrating trauma can perforate the TM. A
hole in the TM is visible on examination, or the examiner may notice an absence of normal landmarks. A
perforated eardrum does not signicantly impair hearing or result in vertigo and usually heals within 4 to
6 weeks without sequelae. Assess the extent of other
damage to the ear when perforation is identied.
Cervical Lymphadenitis
Anterior cervical lymphadenitis is a common cause of
referred ear pain in children. This may be seen with
strep throat, as well as in cases of mononucleosis with
extensive cervical node swelling in adolescents or
young adults.
Referred Pain from Cervical Nerves
CN II and CN III innervate the skin and muscles of the
neck and include the great auricular nerve, which supplies the external canals and posterior auricular area.
Pain is perceived in these areas. The ear examination
will be normal.
Referred Pain from Cranial Nerves
CNs associated with referred ear pain include V, VII,
IX, and X. The trigeminal nerve (CN V) supplies the
anterior portion of the auricle and tragus, the anterior
and superior auditory canal, and the anterior TM. The
facial (CN VII), the vagus (CN X), and the glossopharyngeal (CN IX) nerves innervate the posterior
portion of the TM and the external auditory canal.
Inammation of CN X is associated with lesions
of the larynx, esophagus, trachea, and thyroid. With
referred pain, the structures of the ear will appear
normal.
Temporomandibular Joint Disorder
TMJ disorder is a common secondary cause of ear
pain. Diagnosis of the disorder is likely if palpation
over the TMJ elicits tenderness and movement of the
joint creates a clicking sound. Results of examination
of the ear are normal. Pain also increases with intraotic
manipulation. TMJ pain is often worse in the morning.
The pain can be acute (related to trauma or overextension of the mouth) or chronic (related to dental malocclusion or rheumatoid arthritis).
DIFFERENTIAL DIAGNOSIS OF Common Causes of Ear Pain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
External otitis More common in adults, especially
Acute otitis media More common in children
Otitis media with
effusion
Cholesteatoma Hearing loss; recent perforated TM Pearly white lesion on or
Mastoiditis History of recent otitis media;
those with diabetes, ear pickers,
or swimmers; bilateral itching;
pain
,6 years; those with smoke
exposure, recent URI; severe or
deep pain; unilateral; sensation
of fullness
More common in children but
occurs in adults with recent
URI; unilateral pain; sensation of
crackling or decreased hearing
chronic otitis pain behind ear
Discharge; inflamed, swollen
external canal; pain with
movement of pinna; TM
normal or not visible
Red, bulging TM; fever;
decreased light reflex;
opaque TM; decreased TM
mobility
Fluid line or air observed
behind TM; conductive
hearing loss; decreased TM
mobility
behind TM
Swelling over mastoid
process; fever, palpable
tenderness, and erythema
over mastoid process
None
None initially
Tympanogram
Immediate referral
Radiograph of mastoid
sinuses reveals
cloudiness; referral
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Ear Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Foreign body or
cerumen
impaction
Barotrauma History of flying, diving; severe
Trauma History of blunt trauma,
Cervical
lymphadenitis
Cervical nerves
II and III
(referred pain)
Cranial nerves
(referred pain)
TMJ disorder More common in adults; 50%
AOM, acute otitis media; CN, cranial nerve; CT, computed tomography; TM, tympanic membrane; URI, upper respiratory tract infection.
Both children and adults have pain
or vague sensation of discomfort; decreased hearing
pain; hearing loss; sensation of
fullness; history of recent nasal
congestion
penetrating trauma
History of cervical node swelling;
pain in ear common in children
Pain in skin and muscles of neck
and in ear canal
History, depending on CN involved Test function of CNs V, VII,
related to dental problems;
discomfort to severe pain;
unilateral; pain worse in morning
Visualize foreign body or
cerumen; may detect foul
odor; conductive hearing
loss
Retraction or bulging of TM;
perforation of TM; fluid in
canal
Perforation of TM Radiographs/CT scan
Enlarged, tender, cervical
lymph nodes; may see early
onset of AOM in children
Dermatome evaluation for
cervical nerve involvement
IX, and X; ear examination
normal
Malocclusion; bruxism;
normal external and middle
ear structures and function;
jaw click; abnormal CN
function; ear examination
normal
None
Tympanogram
as directed by injury
Throat culture if
indicated; in
adolescents Monospot
if indicated
None
Radiography/CT scan,
directed by CN
involvement
None
REFERENCES AND READINGS
American Academy of Pediatrics and American Academy of Family
Physicians: Diagnosis and management of acute otitis media,
Pediatrics 113:1451, 2004.
Ishiyama A: Why does air travel cause earache? West J Med 171:106,
1999.
Li J, Brunk J: Otalgia, Emedicine. Available at http://emedicine.
medscape.com/article/845173-overview. Accessed October 6, 2010.
Majumdar S, Wu K, Bateman ND, Ray J: Diagnosis and management
of otalgia in children, Arch Dis Child Educ Pract Ed: 94:33, 2009.
O’Neill P: Acute otitis media, BMJ 319:833, 1999.
Pelton SI: Otitis media: re-evaluation of diagnosis and treatment in the
era of antimicrobial resistance, pneumococcal conjugate vaccine,
and evolving morbidity, Pediatr Clin North Am 52:711, 2005.
Pichichero ME: Acute otitis media, part I: improving diagnostic
accuracy, Am Fam Physician 61:2051, 2000.
C H A P T E R
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15
Fatigue
atigue, also called asthenia, is a constitutional
symptom that can be the result of normal physi-
F
ological consequences of exertion or a symptom
of illness. It is a sensation of profound tiredness that is
not relieved by rest or sleep without an objective nding of muscle weakness. Fatigue can result from any
disruption of energy production. Anemia, decreased
oxygenation of blood, or reduced blood ow limits the
amount of oxygen available to cells. Other factors that
contribute to fatigue interfere with restorative mechanisms provided by sleep and rest, nutritional state, and
mechanisms to remove or regulate wastes of metabolism. When fatigue is associated with cardiovascular or
respiratory symptoms, clues are present that may point
to the cause. However, most patients who have the
symptom of fatigue have a normal physical examination and psychological factors are often a contributing
cause.
Fatigue is classied as physiological, psychological, and acute or chronic. Physiological fatigue is the
result of normal activities that lead to overwork or
exhaustion. Psychological fatigue is often related
to a stressful event. Organic causes can produce
acute or chronic fatigue. Acute fatigue lasts less than
6 months and is often a prodrome to other illnesses,
most often infections, such as endocarditis, hepatitis,
or other acute bacterial or viral illnesses. However,
fatigue can also indicate a disease state, most often
related to hyperthyroidism, hypothyroidism, heart
failure, anemia, chronic obstructive pulmonary disease (COPD), sleep apnea, autoimmune disorder, or
cancer.
Chronic fatigue lasts longer than 6 months, and its
onset is usually slow and progressive. Chronic fatigue
may be an indication of depression, chronic infection,
or systemic disease, or it may be secondary to alcohol
or medication use. Chronic fatigue syndrome is a distinct clinical entity characterized by fatigue that is
persistent or relapses, is not alleviated with rest, and
affects the patient’s ability to function.
184
Fatigue is uncommon in very young children; the
younger the child, the more likely the cause is organic.
Most cases of fatigue in school-age children are related
to acute infection. Fatigue is common in adolescents
because of lifestyle factors, as well as in older adults.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is this really fatigue?
Key Question
n Can you tell me what you mean by fatigue?
Fatigue Versus Weakness
It is important to discriminate between weakness and
fatigue. Often, patients describe muscle weakness
when speaking about fatigue such as, “I am tired all
the time and I feel weak.” In children with weakness,
parents will say the child is oppy or “doesn’t run in
gym like the other children.” An individual tends to tire
easily with metabolic or neuromuscular diseases, such
as hypothyroidism or myasthenia gravis.
Young children tend not to have vocabulary that
describes fatigue; often it is the parent who brings the
child to the clinic. Parents may state that the child is
“lying around” or “I can’t get the child to do anything”
or “she just doesn’t have any energy.” Adolescents will
say they are “always” tired.
Is the fatigue physiological?
Key Questions
n Can you tell me about your lifestyle habits (e.g.,
exercise and diet)?
n Can you tell me about your sleep pattern?
n Do you require naps?
n Do you feel rested when you wake up in the
morning?
n When was your last menstrual period?
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Lifestyle Habits
A history of the patient’s daily living and working habits
may reveal a physiological cause for exhaustion. Erratic
eating patterns, dieting, and missed meals may result in
undernutrition or overnutrition. High levels of caffeine
can affect the amount of energy a person has and can
affect the sleep cycle, causing fatigue. Academic stress,
athletic participation, and employment further contribute
to fatigue in adolescents.
Sleep Pattern
Lack of adequate amounts of sleep is often the cause of
fatigue (see Chapter 28). Adults need at least 6 to 8 hours
of sleep for adequate rest; adolescents, 8 to 9 hours; and
children, 10 hours. Patients with sleep apnea, which is
more common in men older than 45 years, may report
waking up and not being refreshed. Heart failure causes
postural nocturnal dyspnea, leading to difculty breathing at night and disturbed sleep. Early morning wakening
is a symptom of depression, as is excessive sleeping
during the day.
Last Normal Menstrual Period
Fatigue is a common symptom in women. Fatigue is
an early sign of pregnancy, a symptom post childbirth, and a symptom associated with menopause.
Perimenopausal women may have fatigue as a result
of disrupted sleep because of night sweats or hot
ashes.
Do I need to consider an organic cause?
These impairments are correlated with the severity of
fatigue.
Medications
Almost any drug can have fatigue as a side effect. The
most common drugs that cause fatigue are antihyperten-
sive drugs, cardiovascular medications, psychotropic
medications, and opiates. Side effects also occur with
drugs such as sedatives and antihistamines. Many drugs
that cause fatigue are over-the-counter preparations.
Alcohol and Drug Use
Alcohol abuse and use of illicit drugs may be over-
looked as a cause of chronic fatigue in adolescents and
school-age children. This fatigue is due directly to the
substance, usually alcohol or marijuana, and to second-
ary factors such as associated poor lifestyle habits
related to sleep, rest, and nutrition. Family and friends
may express the greatest concerns about fatigue that
affects the patient’s ability to function. The CAGE
questionnaire is a useful screening tool to assess for
alcohol abuse (see Box 3-3).
What other clues can help me rule out
an organic cause?
Key Questions
n Have you noticed a change in appetite?
n Do you have any joint tenderness or pain?
n Have you noticed increased urination?
n What other symptoms have you experienced?
Key Questions
n Do you practice safe sex (if sexually active)?
n Have you ever had hepatitis?
n What medications do you take?
n Do you drink alcohol or use street drugs?
Exposure to Body Fluids
Fatigue may be the initial and most prominent symptom of hepatitis, human immunodeciency virus (HIV)
infection, or acquired immunodeciency syndrome
(AIDS). Hepatitis B can be a sexually transmitted infection through semen or contracted from exposure to
contaminated blood. Sexual practices that traumatize
mucous membranes, such as anal intercourse, increase
the risk of transmission of organisms. The person with
HIV/AIDS experiences cognitive impairment that includes difculty processing complex information.
Appetite
An increased appetite may indicate hypoglycemia. A
decreased appetite may indicate an infectious process.
Weight Loss
Weight loss may indicate malignancy, infection, or poor
nutrition related to depression or lack of information
about a healthy and balanced diet.
Increased Urination
Diabetes mellitus, especially type 2, often presents with
fatigue along with polydipsia, polyphagia, and polyuria.
Joint Tenderness
In children with juvenile rheumatoid arthritis (JRA),
severe fatigue that seems to be more than expected
with the degree of joint involvement is seen. In young
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and middle-aged patients, chronic fatigue syndrome
can involve multiple tender points on the body that are
over joints.
Associated Symptoms
Psychological fatigue is often associated with nonspecic and multiple symptoms, such as muscle aching, abdominal pain, and general lethargy. Organic
causes of fatigue are associated with a few specic
symptoms that worsen over time, such as dry skin
and nails with hypothyroidism or shortness of breath
with exertion or when lying at with congestive
heart failure.
Could this have an environmental cause?
Key Questions
n Where do you work?
n Have you been exposed to any toxins?
n Have you been camping?
Occupational Exposure
Heavy metals and pesticides may cause fatigue and
other neurological symptoms. Soldiers returning from
combat zones, such as the Gulf War, have been found
to have unrelenting fatigue from an unknown cause.
to last more than 2 weeks and is experienced by about
25% of adults. Fatigue may be an early sign of
pregnancy.
Severity
Clinically signicant fatigue may vary throughout the
day but never completely disappears. Children with
Lyme disease and JRA experience severe fatigue that is
in excess of the degree of disease involvement. The
patient may need to limit social functioning and recreational activities as a result of fatigue, which may then
exacerbate mood disturbances, which in turn contributes to fatigue.
Aggravating/Alleviating Factors
Psychological fatigue is usually worse in the morning and physical activity may relieve the fatigue.
Organic fatigue is not associated with intensity or
duration of activity and is not relieved with rest or
sleep.
Fever
Fever generally accompanies infectious diseases, which
are common causes of fatigue (see Chapter 16). Prolonged fever may indicate chronic infection, inammatory disease, or malignancy.
Camping
Lyme disease is carried by the deer tick and may present
with a history of weeks of malaise and chronic fatigue
before any skin manifestations appear.
What else do I need to know about
the fatigue?
Key Questions
n Can you describe the onset and pattern of your
fatigue?
n When did you rst notice this?
n How severe is the fatigue?
n What makes the fatigue better or worse?
n Have you had a fever?
n Have you had any bleeding?
Onset and Pattern
The onset of psychological fatigue is often related to a
stressful event and may have a sudden onset. Fatigue
associated with metabolic causes may have a slow and
progressive onset. Signicant fatigue is considered
Bleeding
Heavy menstrual ow may lead to anemia (see
Chapter 33). Other sources of bleeding, such as gastrointestinal ulcers, polyps, or cancer of the bowel,
may result in occult blood loss and fatigue.
If I suspect a psychological cause, what else
do I need to know?
Key Questions
n Can you describe your stress level and how you
cope with stress in your life?
n Have you recently had a stressful event in your life?
n Do you or does anyone in your family have a problem
with anxiety or depression?
n How are you doing in school?
Stress
Stressful life events increase the risk of depression in
some adolescents and adults. In the presence of organic
disease, stress may be secondary to pain or discomfort
that may disrupt sleep and rest patterns. Deconditioning
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secondary to muscle atrophy with inactivity or bed rest
can lead to fatigue (see Chapter 3).
Anxiety and Depression
Children who have family members with depression
are at a greater risk for depression. Generally, the rst
episode of major depression occurs between the ages
of 20 and 30 and more often affects women. Major
depressive disorder may have a genetic component.
Diagnostic criteria will point to depression or anxiety
as a cause.
School Performance
Decreased academic performance and decreased productivity may be an early sign of low self-esteem and
early depression. Children also may overachieve academically to compensate for their lower self-esteem
and hide their depression.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
A general physical examination, including psychological screening for depression and anxiety, is needed to
make a differential diagnosis of fatigue. The majority
of patients will have a normal physical examination,
but clues can be found for the presence of systemic
disease.
Note General Appearance
Observe the patient entering the examination room
to note any abnormality of gait that may indicate
neurological involvement or generalized weakness.
Observe the patient’s demeanor and appearance for
signs of neglect or a facial expression that might indicate depression or generalized anxiety. In the presence of organic disease, the patient will appear ill;
with psychological stress, the patient may appear
depressed or anxious. Children may appear sad or
irritable.
Take Vital Signs
The presence of fever suggests inammation or infection. Blood pressure reading, pulse rate, and respiratory rate reect the function of the cardiorespiratory system. An elevated pulse rate may be
associated with anxiety, anemia, or hyperthyroidism.
Evaluate the patient for orthostatic hypotension.
Weigh and measure the patient to obtain the body
mass index (BMI); a BMI outside the normal range
can indicate poor nutritional status as well as cardio-
vascular risk.
Inspect Skin, Hair, and Nails
Observe for signs of thyroid dysfunction. Hypothy-
roidism is associated with coarse, dry hair and skin and
thickening of nails. Hyperthyroidism is characterized
by ne, limp hair and warm skin. Look for skin lesions
or rashes that may indicate infection or inammation.
A faint maculopapular rash is sometimes associated
with mononucleosis. Lyme disease is associated with a
macular lesion with a clear center. Atrophic skin of
the lower extremities is an indication of arterial insuf-
ciency and underlying arteriovascular disease. Pa-
tients with anxiety disorders may bite their nails or
self-inict excoriation lesions, usually over the face
and extremities.
Examine the Nose, Eyes, Mouth,
and Throat
Inspect for any signs of infection or inammation
secondary to an allergic response. Petechiae on the
palate may be seen with mononucleosis. Palpate for
cervicofacial nodes. Lymphadenopathy is seen with
HIV, malignancy, and mononucleosis. Inspect mucous
membranes for lesions and moisture. Dry, cracked,
and ulcerated mucosa can indicate a nutritional de-
ciency or dehydration.
Conduct a Cardiovascular Examination
Palpate the anterior thorax for the location of the point
of maximal impulse (PMI) and for lifts or heaves.
Listen for carotid and thyroid bruits. Auscultate the
heart, listening carefully for rate, rhythm, and mur-
murs, especially a late systolic murmur heard loudest
over the mitral area, which may indicate mitral pro-
lapse. An audible S3 or S4 in an adult may indicate
heart failure.
Examine the Lungs
First, observe the patient for ease of breathing and re-
spiratory rate. Note the anteroposterior (AP)/lateral
diameter of the thorax. An increased AP diameter indi-
cates chronic obstructive pulmonary disease (COPD).
Test for egophony, and palpate and percuss the anterior
and posterior thorax to listen for resonance (normal) or
consolidation. Tactile fremitus will increase over areas
of consolidated lung. Listen for rales and wheezes.
Bilateral basilar rales indicate congestive heart failure.
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Barely audible breath sounds are associated with
COPD.
Examine the Abdomen
Begin the examination by observing the abdomen (see
Chapter 2). Observe the intactness and condition of the
skin. A rigid abdomen suggests peritoneal irritation.
Generalized symmetrical distention may occur with
obesity, enlarged organs, uid, or gas. Dehydration or
malnutrition may present as a concave contour of the
abdomen.
Listen for bowel sounds. Anxiety, gastrointestinal
irritation, and hunger can increase the frequency and
loudness of bowel sounds. Depression can decrease
bowel sounds.
Perform general light palpation to assess the skin
and abdominal musculature. Note the patient’s response to the examination. Perform deep palpation
over the liver, spleen, and right kidney. Fist palpation
over the posterior thorax tests for kidney tenderness
associated with pyelonephritis.
Perform a Musculoskeletal Examination
Observe and palpate joints for inammation and swelling. Bilateral tenderness over the major trigger points is
diagnostic of bromyalgia. Test stamina by asking the
patient to perform certain musculoskeletal movements or
to walk a certain distance to evaluate changes in fatigue
level. For example, ask the patient to walk a distance for
3 minutes as far and as fast as they can comfortably and
then assess fatigue level.
Conduct a Neurological Examination
Assess both cognitive and physical function to evaluate
attention span, judgment, memory, and affect. Abnormalities may suggest a psychiatric disorder or brain
pathology. Dementia is also seen in persons with HIV/
AIDS. Test cranial nerves. A change in deep tendon
reexes (DTRs) may indicate thyroid dysfunction. Cerebellar and motor testing will rule out weakness or any
associated neurological pathology.
LABORATORY AND DIAGNOSTIC
STUDIES
Complete Blood Count with Indices and
Differential
A complete blood count (CBC) with indices will provide information about the degree and cause of anemia.
Hematocrit and hemoglobin levels reect the degree
of anemia and the indices point to a cause. Microcytic
hypochromic anemia reects chronic blood loss,
whereas normocytic normochromic anemia suggests
an acute blood loss.
A white blood cell (WBC) count of greater than
12,000/µl indicates inammation or infection. Normally
the circulating neutrophils are in a mature form, known
as segs because the cell nuclei are segmented. Immature
forms are known as bands. Infection will increase the
total number of neutrophils with an increase in the number of immature cells or bands.
Ferritin
Ferritin is a protein that stores iron in bone marrow,
and ferritin levels most accurately reect total body
iron stores. Ferritin levels are low with iron deciency
anemia. In contrast, ferritin levels may be elevated or
normal in anemia of chronic disease or in thalassemias,
caused by a reduction in the life cycle of a red blood
cell (RBC) and the bone marrow failing to compensate
for the loss by increasing RBC production.
Total Iron-Binding Capacity
Iron is transported in plasma bound with transferrin, a
serum protein synthesized in the liver. Total iron-binding
capacity (TIBC) of serum is an indirect measure of transferrin. This capacity may be increased in iron deciency
anemia because although the capacity to bind with iron
is high, hemoglobin is decreased and both mean corpuscular volume (MCV) and mean corpuscular hemoglobin
concentration (MCHC) are decreased (e.g., microcytic,
hypochromic anemia). TIBC is normal or low in chronic
disease, often because of the shorter life cycle of an RBC
and the body’s inability to compensate.
Urinalysis
Dipstick urinalysis can rule out or point to infection or
systemic disease as a cause of the incontinence. Note
hematuria, pyuria, bacteriuria, or the presence of leukocyte esterase or nitrites as indicators of urinary tract
infection. Glycosuria or proteinuria suggests diabetes
mellitus or renal disease. The presence of bacteria,
RBC casts, and WBCs on microscopic examination
indicates urinary tract infection (see Chapter 32).
Erythrocyte Sedimentation Rate
The erythrocyte sedimentation rate (ESR) measures the
rate at which RBCs settle in a tube of anticoagulated
blood. An increase in plasma globulins or brinogen
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causes the cells to stick together and fall faster than
normal. An increased ESR is a general indication of an
inammatory process and does not identify the source.
The ESR is often elevated as a result of acute or chronic
infection or inammatory conditions such as rheumatoid arthritis or temporal arteritis.
Fasting Blood Glucose
A fasting blood glucose level 126 mg/dL will identify a patient who is at risk for diabetes.
Hepatic Function
Obtain aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) values to assess for general
inammation of the liver, associated with hepatitis.
Thyroid-Stimulating Hormone
A serum thyroid-stimulating hormone (TSH) level
identies hypothyroidism.
HIV Infection
An enzyme-linked immunosorbent assay (ELISA) will
rule out HIV infection as a cause.
Tuberculin Skin Testing
A Mantoux test is used to test for tuberculosis antibodies.
See Chapter 10 for a more thorough description of skin
testing for tuberculosis.
Monospot
The Monospot is a rapid slide test that detects heterophil antibody agglutination. It is not specic for Epstein-Barr virus (EBV). It is most sensitive 1 to 2 weeks
after symptoms appear and remains positive for up to
1 year. If chronic fatigue syndrome is being considered
as a differential diagnosis, specic EBV antibody tests
should be considered.
Chest Radiograph
A chest radiograph can reveal the presence of pneumonia, a lesion in the lungs, heart size, or the presence of
uid in the lungs as a result of congestive heart failure.
DIFFERENTIAL DIAGNOSIS
Physiological Causes
Poor Sleep and Rest
In general, total sleep time is greatest during infancy,
decreases in childhood, may increase again during
parts of adolescence, remains relatively stable during
the adult years, and declines during the late years of
adulthood (see Chapter 28).
Total sleep time for the newborn is 14 to 18 hours
a day. As the child matures, the sleep cycle increases
in length and the total sleep time decreases. Sleep patterns of 8 to 10 hours develop during childhood. Many
adolescents need increased amounts of sleep.
Most healthy adults spend 7 to 9 hours sleeping
each day. Older adults sleep less, and may experience
more frequent awakenings during the night; some need
to compensate for this with rest periods during the day.
Poor Nutritional Status
Assessment of nutritional risk is determined by data
from the history and physical examination, food recall
data, BMI (BMI ,18.5 5 underweight; BMI 18.5 to
24.9 5 healthy weight; BMI 25 to ,30 5 overweight;
BMI .30 5 obesity), and waist circumference.
According to Dietary Guidelines for Americans
2010, adults are advised to do the following:
n Eat a variety of fruits and vegetables. Choose ve or
more servings a day.
n Eat a variety of grain products, including whole
grain. Choose six or more servings a day.
n Include fat-free and low-fat milk products, sh,
legumes, skinless poultry, and lean meats.
n Restrict total fat intake to 20% to 35% of calories,
with the majority of fats consisting of polyunsatu-
rated and monounsaturated fatty acids.
n Balance the number of calories you eat with the
number of calories you burn.
n Engage in regular physical activity of moderate in-
tensity for at least 30 minutes on most days.
n Limit your intake of high-calorie, low-nutrition foods.
n Limit your intake of foods high in saturated and
trans-fatty acids.
n Eat less than 2300 mg (1 teaspoon of salt) of sodium
per day.
n Drink no more than one alcohol drink a day if a
woman and no more than two drinks a day if a man.
n Clean hands when handling food; cook foods to safe
temperatures; chill foods promptly; and defrost
foods properly.
Psychological Causes
Depression
About 30% of primary care patients will have depressive symptoms. The adult patient will most often present with a loss of interest in usual activities, feelings of
190 Chapter 15 • Fatigue
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worthlessness and guilt, and thoughts of suicide for
more than 2 weeks’ duration. The practitioner must assess the risk of suicide and intervene or refer to a mental health specialist (see differential diagnosis box in
Chapter 3).
Other symptoms include sleep and appetite disturbances, malaise, and decreased libido. Patients with
bipolar disease may reveal a history of a manic episode
associated with increased activity, increased libido,
and feelings of grandiosity. The physical examination
is usually normal.
Children will appear sad, angry, or irritable. They
may have somatic complaints or low self-esteem and
have problems with school performance. Adolescents
may exhibit euphoria, hypersomnia, and lack of interest in activities.
Anxiety
Diagnostic and statistical manual of mental disorders,
ed 4, text revision (DSM-IV-TR) diagnostic criteria for
anxiety will guide the diagnosis of anxiety disorder or
panic attack. Patients will report a sense of doom and
fear of losing control, dyspnea and chest discomfort,
fatigue, restlessness, and sleep disturbance. Physical
ndings will include tachycardia, palpitations, and diaphoresis (see differential diagnosis table in Chapter 3).
Organic Causes of Acute Fatigue
Infection
The prodrome stage of many viral infections may produce fatigue before other symptoms, such as sore
throat, nasal congestion, and myalgia. Acute hepatitis A
and B can cause fatigue before symptoms of jaundice or
abdominal discomfort appear. Endocarditis, an infection of the heart valves, can cause fatigue.
Drugs
Alcoholism is one of the most common causes of acute
fatigue related to organic causes. Chronic alcohol
abuse is associated with undernutrition, a contributing
factor to fatigue.
Anemia
The fatigue associated with anemia is secondary to the
body’s compensation to increase oxygen in blood that is
oxygen-deprived because of abnormal size or quantity
of RBCs. The body compensates by increasing the heart
rate but may not be able to make up for this decit,
which leads to increased breathlessness with activity.
A diet history may show inadequate dietary intake of
iron or heavy menstrual bleeding. Early symptoms are
fatigue, weakness, and shortness of breath. A CBC will
identify the cause of anemia. Serum iron, serum ferritin,
and transferrin levels may also support the diagnosis of
anemia.
Hypothyroidism (Myxedema)
Patients report cold intolerance, constipation, weight
gain, hoarseness, depression, and fatigue. Physical
examination reveals bradycardia, dry skin, generalized edema, and delayed recovery of deep tendon reexes. An elevated TSH level is present in primary
hypothyroidism.
Hyperthyroidism (Graves Disease)
This disorder is associated with increased sweating,
heat intolerance, weight loss, irritability, disturbed
sleep, and menstrual irregularity. The physical examination may disclose tachycardia, atrial brillation,
tremor, warm moist skin, and lid lag. Graves disease is
associated with exophthalmos. Radioiodine uptake
scan will differentiate Graves disease, toxic nodule,
and thyroiditis.
Organic Causes of Chronic Fatigue
Sleep Apnea
This disorder most often affects middle-age and older
men. Risk factors include obesity and hypertension.
Patients describe excessive daytime fatigue, morning
headaches, and erectile dysfunction. Bed partners of
patients report restless sleep, loud snoring, and periods
of apnea for at least 30 seconds during the night.
Medication
Antihypertensive medications and cardiac medications,
such as ß-blockers, often are associated with fatigue.
Fatigue is a side effect of some pain medications, antihistamines, and many other medications.
Heart Failure
Heart failure is associated with dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, peripheral edema,
weight gain, cough with frothy sputum, palpitations,
and fatigue (see Chapter 10). Persons with a history
of heart disease or valvular disease are at greater
risk. Physical examination may reveal an altered
level of consciousness, anxiety, jugular venous distention, tachypnea, rales and rhonchi, and a displaced
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