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05.05.2014

Alcohol abuse and fatigue, ringing in ears popping - Plans Download

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The history is the most important part of the evaluation of fatigue, while the physical examination and laboratory studies provide supporting data. The evidence on the yield of clinical evaluation is poor, and the recommendations that follow are based on a few observational studies and experts' opinions. Evaluation of medicines, both prescribed and over-the-counter, should be undertaken and recreational drug use carefully explored. Since one quarter to one third of patients presenting with fatigue in a primary care setting are depressed, early diagnosis of depression is important in clinical practice. The 2-question patient health questionnaire (PHQ-2) enquires about the frequency of depressed mood and anhedonia (if people are able to experience any joy or pleasure) over the past 2 weeks, scoring each as 0 ('not at all') to 3 ('nearly every day'). The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire and is especially helpful in identifying less severe drinking problems.
A brief self-reported insomnia questionnaire based on the DSM-IV criteria has been evaluated: this short insomnia questionnaire (known as the Sleep Disturbance Questionnaire or SDQ) has a sensitivity of 95%, a specificity of 87%, and a positive likelihood ratio of 7 for screening insomnia. Performing a physical examination is important not only to rule out specific causes of fatigue, such as cancer or hypothyroidism, but also to ensure that the patient feels his or her complaint is being taken seriously and viewed as a health problem worth investigating. Initial tests to order include FBC with differential, ESR (in patients ≥65 years, ESR helps to screen for systemic disease and neoplasia), chemistry screen (urea, electrolytes, and creatinine) as well as LFTs, fasting blood glucose, and measurement of serum creatine kinase, calcium, phosphate, and TSH levels.


An ECG, cardiac enzymes, and CXR are indicated if an underlying cardiac or pulmonary disorder is suspected.
Further testing for specific underlying causes is highly variable and depends on the clinical evaluation. The carbohydrate-deficient transferrin (CDT) is a useful tool to identify possible chronic heavy alcohol consumption. Addison's disease may be detected on serum cortisol level; however, if this is normal and the disease is clinically suspected, a short ACTH stimulation test should be performed.
The endocrine assessment of a patient with suspected hypopituitarism usually involves measurement of basal anterior pituitary hormones and their respective target gland hormone levels (cortisol, TSH, free T4, free T3, FSH, LH, oestrogen, testosterone, prolactin, and GH). Investigations for possible underlying malignancy will depend on clinical evaluation, and may include chest imaging, imaging of abdomen and pelvis, specimens sent for cytology, or biopsy. Sleep problems such as excessive sleepiness, sleep apnoea, and parasomnias are also investigated in this questionnaire.
The search for pallor, tachycardia, and a systolic ejection murmur should then be undertaken; presence of these signs suggests anaemia. A ferritin level should be measured to screen for iron deficiency (particularly in menstruating females) and a urinalysis performed to detect the presence of protein, blood, and glucose. In patients with suspected cardiac failure, an elevated B-type natriuretic peptide (BNP) and echocardiogram abnormalities will support this diagnosis.


Iron deficiency leads to impaired collagen synthesis, and therefore the choroids can be seen through a thin sclera; this results in a bluish tinge to the sclera.
A formal cardiopulmonary examination should focus on excluding CHF and chronic lung disease, both important causes of fatigue. Finally, a preliminary neurological examination is warranted, including assessment of muscle bulk, tone, and strength; abnormalities would suggest an underlying neurological disorder accounting for the patient's fatigue. Specific testing for Lyme disease involves immunological studies, such as the immunofluorescence assay (IFA) and ELISA studies. Insulin tolerance test (ITT) may be required in some patients at risk of panhypopituitarism, to assess the ACTH-adrenal axis and GH secretory reserves comprehensively. Patients with clinical symptoms or biochemical evidence for diabetes insipidus should have a urine specific gravity and osmolality, and consideration for possible water deprivation or desmopressin tests performed under expert guidance.



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Comments to “Alcohol abuse and fatigue”

  1. TIMON:
    Meaning that the diagnosis comes about as a result will be another.
  2. devo4ka:
    May be helpful in distinguishing insomnia are safe or �natural?doesn�t mean cough, a patient who is crying may.
  3. Nikotini:
    Sinus infections, and allergies - and regular and exercise.