Fatigue (피로)

KEYWORDS: ..For the primary care physician, fatigue is a challenge requiring a broad approach, sound clinical reasoning, negotiation, and interpersonal skills. ..환자들은 대부분 자신에게 어떤 기질적인 질환이 생겼을 것으로 생각하는 경향이 있고 정신적인 증상이 있다고 하더라도 환자들은 그런 증상들이 기 질적인 질환에 의한 2차적인 증상으로 여기는 경향이 있다. 이런 상황에서 주치의가 환자에게 정신적인 원인이 피로 증상의 원인이라는 것을 강조하게 되면 환자는 자신의 증상을 심각하게 받아들이지 않는다고 오해하는 일이 생기기 때문에 조심해야 한다. 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 ▶ Consider psychological screening test (e.g., Beck, Zung) ▶ Consider screening tests for Support and stress (e.g., Genogram, DUSOCS, family APGAR etc) 보통 1년 이상 지속된 만성피로환자의 경우 Laboratory test는 정상인 경우가 많다. ..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 ..피로를 호소하는 환자에게 우울증이 확인될 경우에는 주요 우울증의 범주에 들지 않더라도 TCA나 SSRIs 계열의 항우울제를 소량 사용하면 도움이 된다. ..병력, 진찰, 검사에 의해서 원인이 밝혀지지 않고 스트레스나 우울증과도 관 계가 없다면 환자를 1개월 후에 다시 추적 관찰하는 것이 중요하며, 추적 과 정에서 원인이 두드러진 변화를 보이는 경우가 있다. ▶ 한 보고에 의하면 Physical, Psychologi fatigue 환자의 1년 후 회복율을 비교 했을 때 차이가 별로 없다고 밝히고 있다. 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 참고 문헌 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 신호철 : 피로, in 가정의학 임상편. 서울, 계측문화사, 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