General Surgery Rotation

General Surgery: Fatigue

Fatigue

Fatigue Differential Diagnosis Causes of subacute and chronic fatigue

Condition Symptoms Physical findings Supportive diagnostic studies
Cardiopulmonary
Congestive heart failure Dyspnea on exertion, orthopnea, leg swelling S3 gallop, inspiratory rales, elevated jugular venous distension, peripheral edema Chest radiograph, echocardiogram
Chronic obstructive pulmonary disease Dyspnea, chronic cough, sputum production Evidence of hyperinflation, wheezing, rales Chest radiograph
Sleep apnea Snoring, interrupted breathing during sleep Obesity, hypertension Sleep study
Endocrinologic/metabolic
Hypothyroidism Cold intolerance, weight gain, constipation, dry skin Bradycardia, goiter, slow deep tendon reflex relaxation phase Thyroid function tests
Hyperthyroidism Heat intolerance, weight loss, diarrhea, moist skin Tachycardia, goiter, ophthalmopathy Thyroid function tests
Chronic renal disease Nausea/vomiting, mental status changes, decreased urine Hypertension, peripheral edema Renal function tests/ serum electrolytes
Chronic hepatic disease Abdominal distention, gastrointestinal bleeding Jaundice, palmar erythema, gynecomastia, splenomegaly, evidence of ascites Hepatic function tests
Adrenal insufficiency Weight loss, salt craving, gastrointestinal complaints Hypotension, hyperpigmentation, vitiligo Morning cortisol/ACTH, ACTH stimulation test
Electrolyte abnormalities
Hyponatremia Nausea, malaise, cognitive dysfunction Generally normal exam Serum sodium level
Hypercalcemia Anorexia, polydipsia/polyuria, nausea Generally normal exam Serum calcium/albumin levels
Hematologic/neoplastic
Anemia Dizziness, weakness, palpitations, dyspnea Tachycardia, pallor Complete blood count
Occult malignancy Weight loss, localized symptoms may be present depending upon type Variable Variable depending upon type
Infectious diseases
Mononucleosis syndrome Fever, sore throat, tender lymph nodes Fever, exudate pharyngitis, tender cervical adenopathy Complete blood/differential count, monospot
Viral hepatitis Fever, nausea/vomiting, abdominal discomfort Fever, jaundice, tender hepatomegaly Hepatic function tests, viral hepatitis serologies
HIV infection Weight loss, variable localized complaints Variable physical findings HIV serology
Subacute bacterial endocarditis Fever/chills, night sweats, myalgias Fever, new (regurgitant) murmur, peripheral manifestations Blood cultures, echocardiogram
Tuberculosis Fever/chills, night sweats, fatigue, weight loss Cough, chest pain, dyspnea, hemoptysis PPD/gamma-interferon assay, chest radiograph
Rheumatologic
Fibromyalgia Chronic diffuse muscle pain Multiple "tender points" on palpation None
Polymyalgia rheumatica Aching/morning stiffness of shoulders, neck, and hips Decreased range of motion of shoulders, neck, and hips Erythrocyte sedimentation rate
Psychological
Depression Sad mood, anhedonia, altered sleep, cognitive dysfunction Generally normal exam Screening test (eg, PHQ-2, PHQ-9)
Anxiety disorder Generalized nervousness, panic attacks, phobias Tachycardia, muscle tension Screening test (eg, GAD-7)
Somatization disorder Multiple chronic constitutional and localized complaints Generally normal exam Screening test (eg, SSS-8)
Medication toxicity* Variable Generally normal exam None
Substance use** Variable Generally normal exam None

ACTH: adrenocorticotropic hormone; HIV: human immunodeficiency virus; PPD: purified protein derivative; PHQ-2: Patient Health Questionnaire-2; GAD-7: Generalized Anxiety Disorder-7; SSS-8: Somatic Symptom Scale-8.

* Benzodiazepines, antidepressants, muscle relaxants, first-generation antihistamines, beta-blockers, opioids.
** Alcohol, marijuana, opioids, cocaine/other stimulants.
General Surgery: Anemia (Prev Lesson)
(Next Lesson) General Surgery: Pulmonology (PEARLS)
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