Fatigue (ÇÇ·Î)

The Root of Ambulatory Care
- Àú ÀÚ : ÀÌÁø¿ì
- Ãâ ÆÇ : ±ºÀÚÃâÆÇ»ç
- ÆäÀÌÁö¼ö: 543¸é
ÀÌÁø¿ì ¼±»ý´Ô, ±ºÀÚÃâÆÇ»ç¿Í Á¦ÈÞ¸¦ ÅëÇØ Ã¥ ³»¿ë ¹× ±×¸²À» Á¦°øÇÕ´Ï´Ù.
¹«´Ü º¹Á¦/¹èÆ÷ ±ÝÁö.
KEYWORDS:
..For the primary care physician, fatigue is a challenge requiring a broad
approach, sound clinical reasoning, negotiation, and interpersonal skills.
..ȯÀÚµéÀº ´ëºÎºÐ Àڽſ¡°Ô ¾î¶² ±âÁúÀûÀÎ ÁúȯÀÌ »ý°åÀ» °ÍÀ¸·Î »ý°¢ÇÏ´Â
°æÇâÀÌ ÀÖ°í Á¤½ÅÀûÀÎ Áõ»óÀÌ ÀÖ´Ù°í ÇÏ´õ¶óµµ ȯÀÚµéÀº ±×·± Áõ»óµéÀÌ ±â
ÁúÀûÀÎ Áúȯ¿¡ ÀÇÇÑ 2Â÷ÀûÀÎ Áõ»óÀ¸·Î ¿©±â´Â °æÇâÀÌ ÀÖ´Ù. ÀÌ·± »óȲ¿¡¼
ÁÖÄ¡Àǰ¡ ȯÀÚ¿¡°Ô Á¤½ÅÀûÀÎ ¿øÀÎÀÌ ÇÇ·Î Áõ»óÀÇ ¿øÀÎÀ̶ó´Â °ÍÀ» °Á¶ÇϰÔ
µÇ¸é ȯÀÚ´Â ÀÚ½ÅÀÇ Áõ»óÀ» ½É°¢ÇÏ°Ô ¹Þ¾ÆµéÀÌÁö ¾Ê´Â´Ù°í ¿ÀÇØÇÏ´Â ÀÏÀÌ
»ý±â±â ¶§¹®¿¡ Á¶½ÉÇØ¾ß ÇÑ´Ù.
Common conditions leading to Fatigue, by System and Process
Psychologic : 60~80% ; usually more than 4months
Depression, Stress (social or physical)
Physical & Physiologic causes : 8% ; usually less than 4weeks
Infections Hepatitis, HIV, Mononucleosis
Endocrine/Metabolic Thyroid disease, DM, Menopause, Adrenal dysfunction,
disorders Electrolyte imbalance
Medication side effect Amitryptiline, Doxepin, Trazodone, Reserpine,
or other toxic exposure Methyldopa,Clonidine,Propranolol,Diphenhydramine,
Chlorpheniramine / Carbon monoxide, Gasoline or
organi solvents, Substance abuse
Hematologic disorder Anemia, Leukemia
Cardiovascular disease CHF, Cardiomyopathy,Valvular heart disease
Immunologic/Connective tissue disease (RA, SLE),
Lifestyle (sleep, diet, exercise, work, substance use habits), Malignancy
Despite exhaustive work-up, many patients with fatigue remain undiagnosed.
Fatigue
1. Duration
Less than 4 weeks : likely to be physical
More than 4 months : likely to be psychosocial
2. Character of symptoms
Progressive : may be physical
Worse in morning : may be psychosocial
Worse in evening : may be physical
Non specific and multiple : may be psychosocial
3. Symptoms of depression?
4. Complete drug history : prescribed, over the counter, tobacco, ethanol, herbals,
illicit
5. Underlying disease : Hepatitis, HIV, Thyroid disease, DM, SLE, Anemia, Heart
disease, or Malignancy etc
309
The Root of ambulatory care
Key questions
Characteristics Proposed To Distinguish Psychological Fatigue from Physical Fatigue
Characteristic Psychological Physical
Duration Chronic Acute
Primary deficit Desire Ability
Onset Stress related Unrelated to stress
Diurnal pattern Worse in morning Worse in evening
Course Fluctuates Progressive
Effect of activity Relieves Worsens
Assocaited symptoms Multiple and nonspecific Few and specific
Previous problems Functional Organic
Family Stressful Supportive
Appearance Anxious/depressed
Family history Psychological/alcoholism None
Placebo effect Present Absent
Effect of sleep Unaffected/worsened Relieved
Decreased activity to cope No Yes
Key tests
Key treatments
Fatigue
Level one - laboratory evaluation
..Chest X-ray : The adenopathy, tumors, infection, CHF\CBC
..ESR
..U/A
..FBS/Hepatitis marker/TFT
..Pregnacy test : women of childbearing age
..Age/gender-appropriate cancer screening : pap smear, mammography,
testicular examination, etc
level one test normal, etiology remains unclear
..
Level two - laboratory evaluation
..Electrocardiogram : silent infarction / ischemia
..Serologies for rheumatic diseases : rheumatoid factor, ANA, Anti-Ro,-La
..Drug screen for unreported substances including alcohol
..HIV, PPD, VDRL, Lyme titiers in appropriate patient settings
¢º Consider psychological screening test
(e.g., Beck, Zung)
¢º Consider screening tests for Support and stress
(e.g., Genogram, DUSOCS, family APGAR etc)
º¸Åë 1³â ÀÌ»ó Áö¼ÓµÈ ¸¸¼ºÇÇ·ÎȯÀÚÀÇ °æ¿ì Laboratory test´Â Á¤»óÀÎ °æ¿ì°¡ ¸¹´Ù.
..Diagnosis is mostly based on history and an understanding of the epidemiology
; routine laboratory testing should be minimized.
1. Psychiatric evaluation and treatment if needed.
2. Treat underlying medical disease if present.
3. Empirical trial of antidepressants for 2months or withdrawal of a
medication known to cause fatigue.
Some patients also benefit from moderate levels of exercise and reducing the
stresses in their life.
311
The Root of ambulatory care
..ÇǷθ¦ È£¼ÒÇϴ ȯÀÚ¿¡°Ô ¿ì¿ïÁõÀÌ È®À뵃 °æ¿ì¿¡´Â ÁÖ¿ä ¿ì¿ïÁõÀÇ ¹üÁÖ¿¡
µéÁö ¾Ê´õ¶óµµ TCA³ª SSRIs °è¿ÀÇ Ç׿ì¿ïÁ¦¸¦ ¼Ò·® »ç¿ëÇÏ¸é µµ¿òÀÌ µÈ´Ù.
..º´·Â, ÁøÂû, °Ë»ç¿¡ ÀÇÇØ¼ ¿øÀÎÀÌ ¹àÇôÁöÁö ¾Ê°í ½ºÆ®·¹½º³ª ¿ì¿ïÁõ°úµµ °ü
°è°¡ ¾ø´Ù¸é ȯÀÚ¸¦ 1°³¿ù ÈÄ¿¡ ´Ù½Ã ÃßÀû °üÂûÇÏ´Â °ÍÀÌ Áß¿äÇϸç, ÃßÀû °ú
Á¤¿¡¼ ¿øÀÎÀÌ µÎµå·¯Áø º¯È¸¦ º¸ÀÌ´Â °æ¿ì°¡ ÀÖ´Ù.
¢º ÇÑ º¸°í¿¡ ÀÇÇϸé Physical, Psychologi fatigue ȯÀÚÀÇ 1³â ÈÄ È¸º¹À²À» ºñ±³
ÇßÀ» ¶§ Â÷À̰¡ º°·Î ¾ø´Ù°í ¹àÈ÷°í ÀÖ´Ù.
International Chronic Fatigue Syndrome (CSF) Study Group Case Definition of CSF
In a patient with severe fatigue that persists or relapses for 6 months, classify as CFS
if fatigue is severe and accompanied by at least 4 symptom criteria
Fatigue severity
Fatigue of new or definite onset (not lifelong) and not substantially alleviated by rest,
resulting in substantial reduction in previous levels of occupational, educational, or
personal activities
Symptom Criteria
Beginning at or after onset of fatigue and concurrently present after 6 months
1. Impaired memory or concentration
2. Sore throat
3. Tender cervical or axillary lymph nodes
4. Muscle pain
5. Multijoint pain
6. New headaches
7. Unrefreshing sleep
8. Postexertional malaise.
Fatigue
International Chronic Fatigue Syndrome(CSF) Study Criteria for Exclusion from a
Diagnosis of CFS
1. A documented fatiguing medical disease
2. A previously diagnosed fatiguing medical disease that has not fully resolved
3. A prior or current major depressive disorder with psychiatric features such as bipolar
disease, schizophrenia, dementia, anorexia nervosa, or bulimia nervosa
4. Substance abuse within 2 years of the onset of fatigue
Âü°í ¹®Çå
Anthony L.-T. Chen : Fatigue, in Saunders Manual of Medical Practice, 2nd ed, Robert E.
Rakel(ed).Philadelphia, Saunders, 2000, P 1415-1417
Anthony F. Valdini, M.D., M.S., FACP, FAAFP. : Fatigue, in A Lange clinical manual Family Medicine
Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed).United States
of America, The McGrwa-Hill Companies,Inc., 2005, P 147-152
½Åȣö : ÇÇ·Î, in °¡Á¤ÀÇÇÐ ÀÓ»óÆí. ¼¿ï, °èÃø¹®È»ç, 2002, P 353-360
David C. Klonoff, M.D. : Chronic Fatigue Syndrome, in Conn¡¯s Current Therapy 2004, Robert E.
Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 118-122
Martin S. Lipsky, M.D., Mitchell S. King, M.D. : Fatigue,in Blueprints in Family Medicine. Massachusetts,
Blackwell Publishing, 2003, P 43-45
Timothy craig, D.O., Sujani Kakumanu : Chronic Fatigue Syndrome : Evaluation and Treatment. A journal
of the American Family Physicains 2002 ; 65(6):1083-1090
313
The Root of ambulatory care