Rosen & Barkin's 5-Minute Emergency Medicine Consult (264 page)

• Case appropriately managed by primary care physician
  
• Follow-up is adequate to provide close monitoring of intake and growth.
  

Subspecialty referral depending on cause

• Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency.
  Pediatr Rev
  . 1992;13(12):453–460.
  
• Block RW, Krebs NF, American Academy of Pediatrics Committee on Child Abuse and Neglect, et al. Failure to thrive as a manifestation of child neglect.
  Pediatrics.
  2005;116:1234–1237.
  
• Centers for Disease Control and Prevention, National Center for Health Statistics: Growth charts. Available at
  www.cdc.gov/growthcharts
  . Accessed on April 23, 2005.
  
• Corbett SS, Drewett RF. To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis.
  J Child Psychol Psychiatry.
  2004;45:641–654
  .
  
• Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure to thrive.
  Pediatr Clin North Am
  . 1998;45(1):169–187.
  
• Maggioni A, Lifshitz F. Nutritional management of failure to thrive.
  Pediatr Clin North Am
  . 1995;42:791–810.
  
• McDougall P, Drewett RF, Hungin AP, et al. The detection of early weight faltering at the 6–8-week check and its association with family factors, feeding and behavioural development.
  Arch Dis Child.
  2009;94:549–552.
  
• Shah MD. Failure to thrive in children.
  J Clin Gastroenterol
  . 2002;35(5):371–374.
  

CODES

• 779.34 Failure to thrive in newborn
  
• 783.41 Failure to thrive
  

BASICS

• A subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest
  
• Fatigue occurs with or without objective findings on physical exam.
  
• Fatigue is a common complaint in people with and without systemic disease, which makes this complaint a challenge to practicing physicians.
  

• The specific mechanisms of fatigue are unknown.
  
• Hematologic:
  
  • Anemia
    
  • Leukemia
    
• Endocrine:
  
  • Thyroid disorders
    
  • Adrenal insufficiency
    
  • Diabetes
    
  • Pregnancy
    
• Malignancy:
  
  • Paraneoplastic syndromes
    
• Psychiatric:
  
  • Chronic pain
    
  • Emotional distress
    
  • Depression
    
  • Eating disorders
    
  • Chemical dependency
    
  • Withdrawal syndromes
    
• Sleep disorders:
  
  • Insomnia
    
  • Sleep apnea
    
• Cardiac and pulmonary disorders
  
• Infections acute and chronic
  
• Rheumatic and autoimmune disorders
  
• Nutritional deficiencies including electrolyte abnormalities
  
• Physical inactivity and deconditioning
  
• Medications
  
• Chronic fatigue syndrome:
  
  • Symptom complex defined by the CDC
    
  • Severe chronic fatigue lasting >6 mo
    
  • Not explained by any medical or psychiatric diagnosis
    
  • Presence of 4 or more of the following 8 symptoms:
    
    • Headache
      
    • Arthralgias
      
    • Sleep disturbances
      
    • Lymphadenopathy
      
    • Exercise intolerance
      
    • Myalgias
      
    • Impaired memory/concentration
      
    • Sore throat
      

DIAGNOSIS

• Fatigue is a subjective complaint of exhaustion or tired sensation that interferes with normal activities of life, and symptoms do not resolve with sleep.
  
• There are no specific signs of fatigue, but frequently physical signs may hint at the underlying cause of complaint.
  

• Onset, pattern, duration of fatigue
  
• Associated symptoms: Fever, night sweats, weakness, dyspnea, weight loss/gain, sleep patterns
  
• Past medical and surgical history
  
• Psychiatric history: Emotional and mental stressors, depression
  
• Social history: Alcohol, drug use, major life events
  
• Medications
  
• Full review of systems
  

• A complete physical exam should be focused on trying to identify an underlying cause for patient’s symptoms. No physical findings are specific to fatigue.
  
• A partial list of physical exam findings which may suggest an underlying cause include:
  
  • Vital signs
    
  • HEENT
    
    • Pupils for evidence of toxidrome
      
    • Sclera for icterus in liver disease
      
    • Conjunctiva pale in anemia
      
    • Thyroid for enlargement, pain, or nodule that would suggest dysfunction
      
  • Heart: Murmurs or S3 may suggest LV dysfunction.
    
  • Lung: Abnormal AP diameter or breath sounds may suggest chronic or acute lung disease.
    
  • Abdomen: Tenderness or masses should be investigated.
    
  • Skin: Rash may suggest infectious or autoimmune disease, lack of turgor may suggest dehydration, hyperpigmentation in Addison disease.
    
  • Neurologic: True weakness or areflexia may suggest neuromuscular disorder, all new focal weakness should be investigated.
    
  • Musculoskeletal: Indwelling IV lines or dialysis catheters should prompt investigation of electrolyte abnormality or occult bacteremia.
    

• Because fatigue is a subjective complaint, the essential workup is directed at identification of an underlying cause.
  

• Lab evaluation should be directed by findings of history and physical exam.
  
• CBC:
  
  • Screen for anemia or leukemia.
    
• Serum glucose:
  
  • Both hyperglycemia and hypoglycemia can present with fatigue.
    
• Pregnancy test
  
• Electrolytes with BUN/creatinine
  
• Thyroid-stimulating hormone:
  
  • Screen for hypothyroidism.
    
• Urine drug screen
  

Imaging/special test: Special tests are reserved for evaluation of abnormal physical exam findings or history suggesting further evaluation.

Any diagnostic procedures considered should be reserved for evaluation of abnormal physical exam findings or history suggesting further evaluation.

• Infection:
  
  • Bacteremia
    
  • Urosepsis
    
  • Pneumonia
    
  • Viral syndromes
    
  • Abscess
    
  • Epstein–Barr virus, monospot
    
  • Cytomegalovirus
    
  • HIV
    
  • Human herpesvirus 6
    
• Immunologic/connective tissue:
  
  • Rheumatologic (rheumatoid arthritis, systemic lupus erythematosus, juvenile rheumatoid arthritis)
    
  • Osteoarthritis
    
  • Fibromyalgia
    
  • Myasthenia gravis
    
  • Lambert–Eaton syndrome
    
• Neoplastic:
  
  • Solid or hematologic cancers
    
• Metabolic:
  
  • Electrolyte abnormalities
    
  • Mitochondrial diseases
    
  • Bromism
    
• Hematologic:
  
  • Anemia
    
  • Hypovolemia
    
  • Hemoglobinopathy
    
• Endocrine:
  
  • Hyperthyroid or hypothyroid
    
  • Adrenal insufficiency
    
  • Diabetes
    
  • Hypoglycemia
    
• Neurologic:
  
  • Multiple sclerosis
    
  • Cerebrovascular accident
    
  • Amyotrophic lateral sclerosis
    
• Cardiovascular:
  
  • MI
    
  • Cardiomyopathy
    
  • CHF
    
• Pulmonary:
  
  • Pneumonia
    
  • Chronic obstructive pulmonary disease
    
  • Asthma
    
  • Sleep apnea
    
• GI:
  
  • Reflux
    
  • Peptic ulcer disease
    
  • Liver disease
    
• Autonomic dysfunction
  
• Lifestyle:
  
  • Excessive or insufficient exercise
    
  • Obesity
    
• Psychiatric:
  
  • Major depression
    
  • Anxiety
    
  • Grief
    
  • Stress
    
• Medication related:
  
  • Drug interactions
    
  • Commonly caused by BP, cardiovascular, psychiatric, and narcotic medications
    
• Dehydration
  

TREATMENT