Fatigue and generalised weakness

Chapter 23 Fatigue and generalised weakness



Case 23.1


A 29-year-old female presents with a 10–12 month history of fatigue, nausea, anorexia and generally feeling unwell. She has lost 5 kg over the last year. There are occasional episodes of vomiting. She recalls that 1 year ago she had an acute illness with similar symptoms, in addition to vague, upper abdominal discomfort, jaundice, darkening of her urine and pallor of her stools. That illness lasted approximately 6 weeks, but the fatigue, anorexia and nausea never really disappeared.




Questions



1. What disorder do you think she was diagnosed with 1 year ago?

2. How would you relate her symptoms during that time with the disease process?

3. What are the possible causes of her current complaints?

4. You refer the patient to a medical practitioner. What investigations are required?


Case 23.2


A 52-year-old male presents with fatigue, abdominal distension, and a general feeling of lassitude. These symptoms have been present for about 6 months. He is a heavy smoker and admits to a ‘reasonable’ alcohol intake.


On examination, he appears slightly jaundiced. There are a number of bruises on his hands, legs and abdomen. His abdomen is distended, and you are able to elicit the sign of ‘shifting dullness’. There is no obvious hepatomegaly or splenomegaly. Hands appear normal, and examination is negative for spider naevi, caput medusae and gynaecomastia.




Questions



1. Explain what is meant by ‘shifting dullness’. What is its significance?

2. Why was the patient specifically examined for spider naevi, caput medusa, gynaecomastia, hepatomegaly and splenomegaly?

3. What do you think the examiner was looking for on the patient’s hands?

4. What is your differential diagnosis?

5. You refer the patient to a medical practitioner. What investigations are required?


Case 23.3



History


Jenny is a 48-year-old woman who presents to you with a request for some soft tissue work, as she is constantly plagued by neck and upper back pain. These pains have been an ongoing problem for many years. They vary in site, but seem to be predominantly above and between her scapulae. She regularly has massage to alleviate the pains, which helps only for a few days. During these massages, she has noticed that there are many very tender points on her body. Sometimes she experiences sciatic type pain following deep tissue massage of the piriformis muscle. She also has occasional chiropractic treatment for her neck pain.


Jenny’s major complaint, however, is fatigue. This is not a new symptom, and Jenny admits that she has felt tired for most of her life. The first time that it was especially bad was at the age of 20, when she clearly remembers a point in time when she suddenly felt overwhelming muscle weakness. Jenny even recalls with great clarity where she was seated in a university lecture theatre when the symptoms hit. She managed to make it back home, but the details of her symptomatology over the next few weeks is a bit hazy. She knows she struggled to attend her classes, and missed quite a few of them. She recalls fevers, headaches, sore throat, muscle weakness (predominantly proximal) and overwhelming fatigue. Following this acute illness, the fatigue never really disappeared.


At this time, Jenny started to lose weight, and became somewhat obsessed with her appearance. Although of normal weight, she reverted to a diet of mainly vegetables. This was accompanied by episodes of rather severe abdominal pain and bloating, which was relieved by defecation. Her weight dropped to under 45 kg, and menstruation ceased.


During the following 2 years, Jenny managed to complete her degree, with the help of the drug ephedrine. Her weight eventually returned to normal once her diet improved, the episodes of abdominal pain improved, and menstruation was re-established.


Over the next few years she continued to rely on ephedrine to cope with daily activities. She was employed full-time as a teacher. During this period she married, and her husband encouraged her to see a physician about her health problems. A specialist was consulted, who made a diagnosis.



Questions



1. What is your differential diagnosis for this patient?

Jenny gradually weaned herself off ephedrine, but still struggled with the fatigue and proximal muscle weakness. She also found that she had to be very careful about what she ate, as certain foods would make her bloated and cause her pain. In particular, vegetables such as cabbage, broccoli, cauliflower and beans, plus stone fruit and grapes were the main culprits.


2. Do these foods have anything in common with each other? How might they cause her symptoms?

After the birth of her first child, Jenny experienced some mild post-natal depression. However, after the birth of her second child, the depression was far more severe.


Jenny’s marriage had been deteriorating slowly over the years, and she did not actually recognise herself as depressed. Jenny simply believed that she was a completely inadequate and useless individual, who felt guilty regarding just about everything.


On a visit to her doctor when her child was 6 months old, he told her that she ‘looked bloody awful’, and that he believed that she was depressed. She was referred to a psychiatrist, who diagnosed a major depressive episode. During the exploration of her history, the doctor stated that he believed that her ‘episode’ when she was 20 was probably her first episode of depression, not chronic fatigue syndrome (CFS) as diagnosed by the physician. Her family history included a father who had been diagnosed with bipolar disorder.


3. What are the criteria for a major depressive episode?

Jenny was prescribed tricyclic antidepressants, and after a few attempts at finding the most appropriate type, her depression lifted. She described the feeling of having a veil being lifted, as if she was seeing the world as it was for the very first time.


4. How do tricyclic depressants work? Why do you think that a few different types had to be tried?

Over the next 20 years, Jenny has rarely felt ‘depressed’, although the fatigue has remained. It was never as severe as at was in the earlier days, but she has noticed that over the last year, it has become worse again.


She has been divorced for 15 years, works full-time, and has two adult children who are both studying at university. She states that she is content with her life, but finds the constant fatigue is interfering with daily activities.


Current medications are Zoloft and vitamin supplementation. She has attempted to reduce her dose of Zoloft, but below a specific dose causes the return of her depressed state. She also resorts to Nurofen or Nurofen Plus for her muscle and neck pains.


She has not yet reached menopause, although her periods have become irregular over the last year.


5. What type of drugs are:
a Zoloft

b Nurofen and Nurofen Plus?

6. Now compile a ‘problem list’ for this patient.

7. Which of her symptoms do you think may be related to her depression?

8. Is there any relationship between depression and CFS?

9. What do you need to examine in this patient?


Physical examination













































Vitals •Pulse rate/min 78
•Respiratory rate/min 12
•Blood pressure mm Hg 110/76
•Temperature (degrees C) 36.2
•Height (cm) 165
•Weight (kg) 65
•BMI 24.1
•Temperature (degrees C) 36.4
HEENT Unremarkable
Chest No cardiomegaly, heart sounds normal, no murmurs, chest clear
Abdomen Soft, non-tender, no masses
Neurological No objective loss of muscle power
Musculoskeletal
• Significant tenderness of the following muscles: temporalis and masseter, supraspinatus, trapezius, rhomboids

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Fatigue and generalised weakness

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