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S2D: The Symptom to Diagnosis Podcast - Episode 21: Fatigue
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S2D: The Symptom to Diagnosis Podcast - Episode 21: Fatigue
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Language: EN.
Segment:0 .
[upbeat intro music] [upbeat intro music] [upbeat intro music]
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we are here with another episode of S2D, the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. We begin each episode with a case unknown to one of us, we then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experience, but because protecting patient privacy is part of our oath, we never discuss actual patients, and most cases are composites. What are we talking about today, Scott?
DR. STERN: Well today, we're talking about fatigue.
DR. CIFU: Ooh, exciting. So, you're the expert of the day. Do you have a case to present to me?
DR. STERN: I do, and I bet you I stump you.
DR. CIFU: Well, you sent me that email saying, like "You better get your thinking cap on for this one."
DR. STERN: Yeah.
DR. CIFU: I barely slept last night.
DR. STERN: Yeah. Ah, you're tired!
DR. CIFU: [chuckles]
DR. STERN: I was going to present you myself, but actually I am not going to do that. So, how about this? I saw a 40-year-old man, sometime recently actually, who complained of fatigue. He's had it, he says, for about 10 years, and he was diagnosed with chronic fatigue syndrome, but came to me for a second opinion. He notes he sleeps well, but he's often tired during the day and feels tired a lot of the time.
DR. STERN: Review of systems and his physical exam were unremarkable.
DR. CIFU: That's all you're giving me?
DR. STERN: That's all you get. From here on, you're on your own.
DR. CIFU: Okay. So, I'll tell you a little bit about sort of where I'd start and I think probably some of these points you're also going to pick up on later, so I won't get into too much depth. I think something I know you and I have talked about in the past is always characterizing fatigue, right? Fatigue has to be like the least specific complaint, maybe just in front of dizziness, would you say? [chuckles]
DR. STERN: Right, totally.
DR. CIFU: And so people use fatigue to sort of describe everything. So, I'd really hammer on this guy. I'd make sure he's not talking about dyspnea, I'd make sure he's not talking about dizziness. I really want to hear that it's fatigue, it's he's tired. He feels like he needs to take naps, things like that, during the day. I'd want to get a good past medical history. Make sure I know what disease or illnesses he has or has had in the past.
DR. CIFU: I'd like to know if he's taking any medications, I'd certainly like to know that. I'd really spend some hard time on what his sleep is like. I'd really spend some hard time on what his sleep is like. You know, how long he sleeps for? What wakes him up during the night, if he wakes up during the night. If he's got a bed partner, I'd love to hear about snoring, kicking the blankets off in the night, getting up screaming, all sorts of things like that.
DR. CIFU: I think I mentioned medications already, and then probably the last thing as far as really common things is, I'd want to screen him for depression and anxiety, things like that. If I've got no clues on that, and you're telling me a review of systems and maybe a passible internist's physical exam, and maybe a passible internist's physical exam, I would then send some sort of screening blood tests.
DR. CIFU: For me, that's usually CBC, CMP, TSH. For me, that's usually CBC, CMP, TSH. You know, I might even go so far as to send a sed rate if I'm, you know, worried, and then I'd kind of go from there, I think.
DR. STERN: Well, I think that's pretty good. How many of those things do you want now, and how much do you want me to proceed with the case?
DR. CIFU: Why don't we go into your discussion, and then we can get back to that afterwards.
DR. STERN: Okay.
DR. CIFU: Okay.
DR. STERN: Well, you know, in terms of the pivotal points about fatigue, the first one you've already mentioned, which is absolutely right, which is to figure out whether or not people really mean tiredness or fatigue, or whether they mean something else. So, some patients who are sad and depressed complain of feeling tired. Some patients who are short of breath will say that they're fatigued.
DR. STERN: Some patients who are physically weak from muscular problems will also say that they're fatigued, angina sometimes people will describe as feeling fatigued. So, it really is critical for us to say exactly, what do you mean?
DR. CIFU: Weakness is a good point, I didn't think of that and didn't say that when I was talking before, but that is a good thing to bring up, because I can think back to one person in my career who was actually presenting with dermatomyositis who presented as fatigue, and it really was not fatigue. It really was weakness.
DR. STERN: Right, and the clues to those patients will be when you ask about that, if you ask them further, and they say they're weak is, you know, and then you ask them, what do they mean, and often those patients might say, they're having trouble getting out of a chair, they're having trouble going up and down steps, and then all of a sudden, you're on a different pathway altogether. My next pivotal point is for the patients who actually are tired, I think the sleep history, like you say, is key, and this is one of those times when you have to be an internist and be detailed.
DR. STERN: What time do you go to bed on average? What time do you wake up, you know, in the mornings on average? How often are you up at night? Why are you up at night? And asking about what the partners observed during sleep. The most common thing I would say for why people are tired is because they don't get enough sleep, especially in the United States.
DR. STERN: I mean, it's been well documented that many Americans don't get enough sleep, and feel that six to seven hours of sleep is enough, when the fact is many people need eight to nine hours sleep. I actually really like nine hours of sleep, but that's just me. But anyway, that's really important.
DR. CIFU: I'm exactly the same way. I don't think I need nine hours of sleep, but when I'm on vacation with nothing going on, that's usually how much I sleep.
DR. STERN: And it feels good, right? I mean, you wake up feeling like you've had the cup of coffee before you've had the cup of coffee. While we're on the sleep issue, the other thing that I want to bring up is many patients wake up during the night and don't appreciate that that's from alcohol and/or caffeine. So caffeine has a very long half-life and many patients need to stop drinking it around noon, if it's really going to be out of their system by the time they go to bed at night.
DR. STERN: And so, they don't perceive it because it doesn't stop them from falling asleep, just like alcohol doesn't stop you from falling asleep, but it creates a restless sleep. And so I spend a lot of time educating patients who are having trouble sleeping, about caffeine and alcohol.
DR. CIFU: The other thing you need to master is, for the people who recognize that they're not sleeping enough, but can't sleep, what do you do, right? And that certainly maybe starts with alcohol and caffeine counseling. It goes through all of the sleep hygiene counseling. We're very lucky here, and I think there are, in many places, really good people, psychologists who actually do work with CBT, cognitive behavioral therapy for insomnia, which if people are not sleeping well, even after you've gone through your sort of quick, you know, 10-15 minutes sleep hygiene spiel, those specialists can sometimes be really helpful.
DR. STERN: That's true. The next step is actually what you've said. So the third point is-- You know, the first was again, you know, is it fatigue? And the second one is what's their sleep like? The third one is the review of systems and the physical exam. You know, we've seen people come in in atrial fibrillation, they don't know that they're in it and they're tired or they have bad COPD, and it's just embarrassing, frankly, that you miss a major medical condition because you didn't do a history and a physical exam.
DR. STERN: So, you know, I have to say the yield is low, but it's important when you find something.
DR. CIFU: Right, and it's good to point out, I mean, you mentioned right there, atrial fibrillation, COPD, I might add heart failure. So, someone might hear that and say, "Oh, that's fatigue, which is shortness of breath or decreased exercise tolerance." Not true, actually. I mean, those can be people who truly, truly describe fatigue as we're defining it, and their fatigue is due to their heart failure or their atrial fibrillation.
DR. CIFU: And you can do a whole lot of hand-waving and say, "Oh yeah, you know, heart failure causes fatigue because there's poorer forward flow and perfusion." Who the hell knows? You know, but the fact is they're tired.
DR. STERN: Right. Totally, totally. I've seen that with COPD as well. The next step is to do what you've said. I typically do a TSH, a CBC and a CMP. You mentioned a sed rate. I think if I was getting a sed rate, I'd just mention how to interpret it, which is a normal sed rate really doesn't tell you anything, but a very abnormal sed rate would simply tell you you need to look a lot harder.
DR. STERN: So, I just want to emphasize how they might interpret the sed rate if they were to get one. Do you agree with that?
DR. CIFU: I do, and I'm embarrassed to say that I send sed rates and CRPs. I tend to send them when I'm a little bit confused and I'm like, "Do I really have to worry about this person?" And if it's negative, I'm reassured, if it's positive, it basically just says, you got to think more about this case because you're missing something.
DR. STERN: Exactly. And the last point is to consider obstructive sleep apnea, one of the most common causes of fatigue in patients whom their prior workup has not been helpful, especially if they're really complaining of excessive daytime sleepiness, where they're falling asleep all the time.
DR. CIFU: And I might broaden that out a little bit, you know, you're totally right. When you think of sleep disorders that cause fatigue, obstructive sleep apnea is probably, I don't know, one through 10 maybe, but there are things like paroxysmal leg movements of sleep, like REM behavioral disorder, which can also disrupt sleep enough to cause fatigue and on all of these, including obstructive sleep apnea, you know, maybe by getting a history from a bed partner, you can get some assistance, but that's certainly not 100% sensitive, right?
DR. CIFU: And so very often if you've gotten to this point, you're like, "I'm still confused." You know, a sleep study might give you information that you weren't getting otherwise.
DR. STERN: You know, the REM behavioral disorder, we've talked about this before, it's kind of a funny thing, right? It's where your locus coeruleus, which is supposed to lock you down while you're dreaming, fails, and all of a sudden you're moving. And I had this happen one time and slugged my wife. I was having this nightmare and all of a sudden I broke free in the nightmare of the person who was holding me and slugged the person in my dream.
DR. STERN: But unfortunately it turned out, well, of course it was my wife that was in the bed. And she took the brunt of that anyway.
DR. CIFU: How does she put up with you?
DR. STERN: Well, that's a separate issue for another podcast, perhaps.
DR. CIFU: Okay, so let's get back to the case. So I asked you for a lot of information because you basically-
DR. STERN: You did.
DR. CIFU: -gave me nothing upfront.
DR. STERN: I did.
DR. CIFU: So anything turn up in the-
DR. STERN: Well, going through things systematically, one is, it did seem that it was fatigue. He wasn't short of breath, he wasn't having any discomfort anywhere. He was tired all of the time and felt like he didn't have much energy. He did say in terms of his sleep, that he was sleeping well, he was going to bed at 10 or 11 o'clock at night, normally waking up at six or seven, but often wanted to rest during the day.
DR. STERN: He wasn't really drinking alcohol or caffeine. And you know, he wasn't on any medications. As I mentioned, I went through the review of systems and physical exam and they were completely unreliable. And then you asked for labs. So, his TSH was normal. His CBC showed a white count of eight, his hemoglobin was 10, his hematocrit was 30. His MCV was 70 and his comprehensive metabolic panel was normal.
DR. STERN: So, Dr. Cifu?
DR. CIFU: So that guy's anemic. And I think that's the one thing which sort of jumps out at me from there. And it's the kind of anemia that when, you know, you're on the inpatient service in the hospital, you don't even look at, but in the outpatient setting, man, that is abnormal. Now the question is, is that chronic or not? Right? I mean, it's a microcytic anemia. He could conceivably have chronic thalassemia, in which case you wouldn't really think of that as a cause for fatigue.
DR. CIFU: But I think where I'd start is, you know, get me some old records and then let me certainly start with iron studies, you know, maybe hemoglobin, electrophoresis. But I'd probably hold off on that until after the iron studies come back.
DR. STERN: So it gets more interesting.
DR. CIFU: Oh good.
DR. STERN: His old studies show that he was not always anemic.
DR. CIFU: Okay.
DR. STERN: And his iron studies showed a ferritin of 10.
DR. CIFU: Huh. So it sounds- You're looking at me like this should be more interesting than I think it is. So it sounds like he's got iron deficiency anemia, and it's a new iron deficiency anemia. And so now, and we've talked about this a little bit, you know, I'd broaden out into what's my differential diagnosis for iron deficiency anemia, right? So overwhelmingly, and I'm looking back here to see, you told me he was in his early forties, you know, first and foremost would be GI blood loss.
DR. CIFU: And so I'm definitely thinking about scoping this guy, above and below. He's young for a colon cancer. You know, this colon cancer would have to start with a polyp in his thirties, maybe there's a family history, maybe not. But I think hearing about this, I would also be asking him questions about his diet. And I'd be thinking that if they don't find a bleeding site and most gastroenterologists will just do this, he should get a small bowel biopsy for celiac disease while they're in there.
DR. CIFU: I guess you could send antibodies for celiac disease too, but yeah, you're going to be testing, just biopsy that guy.
DR. STERN: Very well done, Dr. Cifu. So this fellow did turn out to have sky high celiac antibodies and an endoscopy did confirm that in fact he had celiac sprue.
DR. CIFU: Wow.
DR. STERN: So here's a guy, it just is a great case, who came in with just- Somebody had said he has chronic fatigue syndrome because he'd been chronically fatigued and didn't evaluate him properly. And he actually had a significant underlying condition that was treatable easily, right? All I had to do is change his diet and he's felt better than he's felt in years.
DR. CIFU: Well, easily changing his diet is probably easier for the doctor to say, than the patient.
DR. STERN: Fair enough.
DR. CIFU: Can I ask you about that? You know, maybe you'll be making this up or maybe based on the cases that this is based on, you can give me a little bit of information. It sounds like the way that you put this together, he was probably fatigued even before his anemia, which I imagine is quite possible with celiac disease.
DR. STERN: I think that's probably true-
DR. CIFU: Yeah.
DR. STERN: -judging from the old records because he wasn't always anemic.
DR. CIFU: Okay.
DR. STERN: And actually,
DR. STERN: in retrospect, when I asked him about GI problems, he said, "Well, over the years, every now and then, I've had troubles and I've kind of started avoiding certain foods." So he had started to kind of realize something was wrong, but it wasn't part of his complaints at all.
DR. CIFU: That's a great case. It's interesting when I think about celiac disease, it's easier to diagnose now than it used to be. But I think it's the minority of people in whom I've made diagnoses that their GI symptoms were, you know, predominant. It was mostly abnormal blood work and things like that, which led to the diagnosis.
DR. STERN: Well, that's interesting. Yeah, it certainly was for him. And by the way, it's worth pointing out that had his antibodies been negative, it doesn't completely rule out celiac disease if he was already on a gluten-free diet. The antibodies can become negative if patients have followed a gluten-free diet. Biopsies may also convert to normal. You can check haplotypes, but that's getting into the weeds a bit.
DR. STERN: Everybody who has celiac sprues seems to have one of two haplotypes. I believe it's DQ2 or DQ8. So-
DR. CIFU: That's just showing off. [chuckles]
DR. STERN: Just saying.
DR. CIFU: Okay, now we're going to move on. Fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge. Scott, want to start us off with fingerprints?
DR. STERN: I don't have any.
DR. CIFU: Yeah, me neither. It's interesting just to say, you know, fingerprints is always the first thing we discuss after the case, we often don't have fingerprints and that just shows you that fingerprints, things that you find on the history or physical exam, which really have very high positive likelihood ratios, and really help to make a diagnosis, they don't often exist. And so it's there for a reason. How about common misconceptions?
DR. STERN: Right, I guess I'll get at, really, there's no simple pill for fatigue. I think my patients want this often, they want to come in and have me give them something, but whether you're talking about antidepressants or sympathomimetic stimulants or non-sympathomimetic stimulants like Provigil, usually when you talk about treating fatigue, you've really got to get at the underlying cause. And often that's a lot- Actually, the most common treatment is working on their sleep by far and away.
DR. STERN: But if they have an underlying, like for this patient, illustrates you have to know what's wrong with them, or you're not going to make him better.
DR. CIFU: Yeah. And I might actually even hazard to say that if you take all the patients who come into a primary care physician's office with fatigue, you know, how many of those actually have an underlying diagnosis and how much of it is just part of the human condition? [chuckles]
DR. STERN: What would you guess? I think the number is really low, the number that we define a condition in.
DR. CIFU: Right, I think probably the majority are sleep disorders, and if you take that away, I think it's less than 10%.
DR. STERN: I agree. It's uncommon.
DR. CIFU: Yeah.
DR. STERN: All right.
DR. STERN: What about you? Do you have a misconception?
DR. CIFU: This might be almost the opposite of what we just talked about, is the misconception that narcolepsy is a rare disease, is the misconception that narcolepsy is a rare disease, and that always presents with like cataplexy, you know, with someone who you're sitting there at lunch with, they laugh at a joke and they fall asleep, right? Which would be an easy diagnosis. In fact, narcolepsy is not that rare, and it can be pretty hard to diagnose.
DR. CIFU: The classic tetrad, which we teach medical students, chronic daytime sleepiness, various amounts of cataplexy, and these two, kind of cool things, hypnagogic hallucinations, which are like, as you're falling asleep, these incredibly well-formed, often frightening hallucinations, and sleep paralysis, where you wake up and you can't move.
DR. STERN: How terrifying would that be?
DR. CIFU: That would be terrifying, right? All patients with narcolepsy have sleepiness, but only about a third of the patients, you know, have the tetrad, it's one of those tetrads which actually doesn't really exist. It's usually a triad that doesn't exist, here is a tetrad which doesn't exist. And so you should think about narcolepsy in people who have really severe daytime sleepiness, and then really ask them carefully about the cataplexy beause that's often something which starts really mild and then worsens as their disease progresses.
DR. STERN: Can you define that for us?
DR. CIFU: Cataplexy is really having sleep I'm trying to remember the proper word - it's basically half-sleep, which, you know, invades on wakefulness. So there are people who are awake and then really suddenly fall asleep. It's often induced by strong emotions. So, laughing, fright also often will bring it on.
DR. STERN: How weird is that?
DR. CIFU: Yeah, and actually- I can't go into it as you went into the celiac haplotypes, but there's interesting, sort of known pathophysiology about what's happening in the brain to cause it.
DR. STERN: Well, maybe you can get back to us in the next podcast on that.
DR. CIFU: [chuckles] I'll do one by myself.
DR. STERN: Now, hypnagogic hallucinations though can be normal. Correct?
DR. CIFU: It can be, and actually, I shockingly remember this from medical school, so there are hypnagogic hallucinations and hypnopompic hallucinations, right?
DR. STERN: Right, now you got me, what's that?
DR. CIFU: That's when you're waking up rather than falling asleep-
DR. STERN: Oh, interesting.
DR. CIFU: -and those are actually very non-specific, and a lot of people have those where in that period where you're just waking up from sleep and sort of awake and asleep, you're almost dreaming, though you're actually awake, you're not in REM sleep, but you're having that.
DR. STERN: And how do you say that word again?
DR. CIFU: I think it's hypnopompic.
DR. STERN: There we go.
DR. CIFU: Yeah.
DR. STERN: All right. So should we go to pet peeves?
DR. CIFU: Let's go to pet peeves, you start us off.
DR. STERN: All right. So, you know, my first pet peeve actually applies to myself a little bit, but you know, I do have a lot of patients who are getting older as I am, who are used to being quite driven and complain that they are fatigued and more fatigued than they used to be when they were younger. And the fact of the matter is it can be tough to sort out. You know when a patient's 80, they don't have the energy of when they were 60, and when we're 60, we don't have the energy of when we were 40 or 20.
DR. STERN: So there is kind of this normal age-related phenomenon that we don't like to admit to, but it's definitely true, where we don't have the energy we had before. And I spend a fair amount of time telling my patients they shouldn't expect to be 20 or 40, when they're 60 or 80.
DR. CIFU: Yeah. That's a tough one because, I think we both certainly subscribe to this, you know, there are a lot of things that shouldn't just happen as you get older, right? You shouldn't become anemic when you get older, I can't think of all the ones that I usually say.
DR. STERN: You shouldn't have chest pain.
DR. CIFU: Shouldn't have chest pain because you get older. You shouldn't get weight loss when you get older. And people should expect to feel well as they get older. But, you know, there are some things which change, right? There is benign senile forgetfulness, right? The problems remembering names, walking into a room, forgetting what you came in there for. You know, those are normal. A little bit of increased fatigue, normal. And it's hard to figure out what should you accept with age, and what should you as a doctor say, "Uh-huh, we got to get into that."
DR. STERN: Changes in libido.
DR. CIFU: Changes in libido.
DR. STERN: Okay, do you have a pet peeve for us?
DR. CIFU: Yes. So it's interesting, this is actually similar to yours. This is what just what happens in, I don't know, 21st century America, often with people getting older. So the pet peeve is diagnosing insomnia when people are just not sleeping the way they want to. Right? So the definition of insomnia, and I looked this up for this, is, "A repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep, and most importantly, results in some form of daytime impairment and lasting for at least a month." And so I have a lot of patients, mostly older patients, who have a period of wakefulness in the middle of the night, where they'll sleep well early, they'll sleep well late, but there's a period in the middle of the night where they don't sleep well.
DR. CIFU: That's normal. And the people will usually say, "I feel fine during the day, it's not causing me any problems," but they're like, "I feel like I should be sleeping solidly from 10 to 6 with no problem." And you know, the worst thing you can do for those people is medicate them because then generally, you're making them hung over in the day, you're making them fall in the middle of the night when they wake up.
DR. CIFU: And what you should say is "That's normal. Accept it. Maybe get up and read a book, get some work done."
DR. STERN: That's really interesting point. That is really common.
DR. CIFU: Yeah.
DR. STERN: I would just say, when I do see those folks, as I said earlier, I do ask them about alcohol and caffeine because that is the subset where you might find something that's fixable.
DR. CIFU: Absolutely.
DR. STERN: Well, my next pet peeve has to do actually, with something about our case, so chronic fatigue syndrome. So let me just say that when we call something a syndrome, it's normally a constellation of signs and symptoms where we don't really know what the pathophysiology is, and we say, it looks similar to other people and we give it a name, like chronic fatigue syndrome. And the problem with these wastebasket terms is, that hides the fact that there are many different diseases that can actually cause chronic fatigue.
DR. STERN: And chronic fatigue syndrome is pretty imprecise. It's a description, but many patients, like our patient will come in, saying they have chronic fatigue syndrome because they're chronically tired and meet the criteria, and yet some of them are depressed, and some of them are anemic, and so on and so forth. So I really dislike the term "syndromes" in general, and I really, seriously dislike chronic fatigue syndrome. And I think it'd be better when we see these patients, as a rule of thumb, to say they have chronic fatigue NOS, if we can't figure out what the cause is, rather than saying chronic fatigue syndrome, as though we've made a diagnosis.
DR. CIFU: Yeah, we could probably do a whole podcast about this, right? Because I think fibromyalgia may fall into the same category. And what's tough about these diagnoses is, I agree, right, it's a syndrome, which means it's almost certainly a wastebasket for multiple different things which have similar symptoms, and ideally what happens over time is we better define a symptom complex, right? is we better define a symptom complex, right?
DR. CIFU: Which gets narrower and narrower, which then allows us to kind of figure out a single pathophysiologic entity, right, that we can diagnose and we can treat. The hard part about this is that often people are lazy, right? And so people will come in and say, "Oh, it's chronic fatigue syndrome or it's fibromyalgia" just because someone's tired and achy or whatever.
DR. CIFU: And that doesn't help anybody, right? It doesn't help the patient, it certainly doesn't help medicine in general moving forward.
DR. STERN: Well, patients sometimes do feel better getting a diagnosis-
DR. CIFU: Yeah.
DR. STERN: -but it's misleading, right?
DR. CIFU: True.
DR. STERN: And I think
DR. STERN: what you said is true in that we get better and better with time about better defining our illnesses so that we can target our therapies better. I mean, look at cancer now. Lung cancer's not just lung cancer, and non-small cell cancer's not just non-small cell cancer. We're at the mutational level. And so we'll continue to do better.
DR. CIFU: As far as where we are with chronic fatigue syndrome, and I know you know this, you mentioned a lot of this, the new term is myalgic encephalomyelitis, which, I think, is maybe worse because it's encephalomyelitis, that sounds like, I'm not sure what that sounds like, but it sounds like encephalitis. There's no inflammation here, right, that we're picking up.
DR. STERN: Right. Right. It's not part of the criteria, actually.
DR. CIFU: Right.
DR. CIFU: And if you look at what the Institute of Medicine defines this, symptoms are present for at least six months, moderate, substantial or severe intensity, at least one half of the time. And in addition to fatigue, other criteria include post-exertional malaise, unrefreshing sleep, cognitive impairment and orthostatic-related symptoms. And as I think of my practice, I have a couple of people who actually fulfill that, but it's a couple of people.
DR. CIFU: And that's where, I don't know, let's just say 25% of my patients would say, "Yeah, I'd like to have more energy."
DR. STERN: All right, so let's go on to pearls.
DR. CIFU: Okay. Why don't you start us off?
DR. STERN: Well, I think the first pearl I'd say is, I've had to learn that obstructive sleep apnea does not simply limit itself to obese patients.
DR. CIFU: Yeah.
DR. STERN: That we occasionally see people with OSA who are normal weight, and we tend not to think about it until much later than we do in a patient who comes in who's significantly obese.
DR. CIFU: Right, I think that's true. And I'm sure that even being aware of that, that I undertest. I think that most of the sleep studies I order are positive, which I don't take that that means I'm a perfect diagnostician, I take it that it means I'm probably undertesting. Right?
DR. STERN: Me too, I think.
DR. CIFU: My pearl, I have probably said this is, it's not glamorous, most people don't find it interesting, but you really got to get a good sleep history. You got to ask people, "When do you go to sleep? When do you wake up? How many times do you wake up during the night? Why do you wake up during the night? Do you nap during the day? Do you feel well rested when you wake up? Do you snore?
DR. CIFU: If you have a bed partner, you know, what do they say about your sleep?" Because all of that information is critical if you're dealing with a fatigued person who doesn't seem to have a real "medical cause."
DR. STERN: That's great. The next one I would throw out, I know you're going to push back on this, I'm going to get a lot of flak for it, but I can't resist myself. We do always talk about screening for hypothyroidism with the TSH, and the overwhelming majority of the time, that's all we need to do. There are rare cases, I've had several in the course of my career, people with secondary hypothyroidism, where of course the TSH is normal and the FTI is low.
DR. STERN: So if somebody has central nervous system disease, like for instance, sarcoidosis or some other process that's affecting their brain, or you're really convinced something is wrong and you're not getting anywhere, you should think about getting an FTI in addition to a TSH. Okay, Dr. Cifu, I know you're going to give me flak about this one.
DR. CIFU: Jesus Christ.
DR. STERN: I told you.
DR. CIFU: You're like some sort of pituitary endocrinologist.
DR. STERN: I've seen many pituitary problems, as a matter of fact, because I know when to look for them, Dr. Cifu.
DR. CIFU: I think what I would say is that TSH is your screening test. If your TSH is elevated, TSH is your screening test. If your TSH is elevated, then you should do an FTI because it is true that like, I mean, not frequently, but I don't know, once every decade, your high TSH is actually associated with a high FTI and you're like, "Huh, how about that." You know, that's central hyperthyroidism, right? But I would like to review every chart for your entire career on how many people you find who have a normal TSH with an abnormal FTI.
DR. STERN: I can tell you, there's two. [both chuckle]
DR. CIFU: Okay, good. You saved me some time.
DR. STERN: All right, your turn. I knew this was going to create some controversy.
DR. CIFU: I got one more real quick. Think about medications, right? And it doesn't just have to be, you know, sleep aids. Think about psychiatric meds that a patient might be on, think about antihistamines and really just go through the history to say like, "You know, if your insomnia started in January, let's talk about medications, over-the-counter and prescription, which may have played a role in that."
DR. STERN: I think it's a really good point, especially about the antihistamines because the over-the-counter antihistamines that are marketed as being non-sedating, sedate some people.
DR. CIFU: Right, and often cause other symptoms. So, you know, you take a 60-year-old man, you put him on an antihistamine, not only are you going to make him tired because of antihistamine but he's going to wake up more during the night to go to the bathroom and that's going to make him more tired too.
DR. STERN: True. All right, my last one is, actually I found very helpful over time, which is if you have someone with chronic fatigue who has multiple apparently unrelated somatic complaints that a limited workup is not revealing for, those multiple somatic complaints do make it more likely that there's a psychiatric illness. So what I found in my own visits is, oftentimes earlier on in my career, I'd start to get triggered by the patient who had four, six, eight unrelated somatic complaints, I'd start to get nervous about working them all up.
DR. STERN: And now I've come to realize that that's, in and of itself, its own clue, that when I start to get that, I start to think to myself actually, what I really need to be exploring is what's going on psychiatrically for the patient.
DR. CIFU: That's terrific. And I'll just point out that it's not only, well, it's what you said in two ways, it's recognizing that this person has multiple somatic complaints, it's also recognizing the way you react to the patient. Right?
DR. STERN: Right.
DR. CIFU: As you get good at this, you should work on sort of mindfulness. How am I reacting to the patient? Because very often you, yourself and your reactions to people kind of become a diagnostic tool, and like, I know, when I want to grab someone by the lapels and say, "Snap out of it," that's a diagnostic clue for me. I don't do that, by the way.
DR. STERN: Oh, well, that's good. I'm happy to hear that.
DR. CIFU: Okay. We hope you found this episode of S2D, the Symptom to Diagnosis podcast, useful and a bit enjoyable. As a reminder, our textbook, Symptom to Diagnosis: And Evidence-Based Guide, takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print at all the usual places, on your mobile device and also available, and fully searchable, via the Access Medicine website, available worldwide from McGraw Hill.
DR. CIFU: The music for the S2D podcast, which is terrific, is courtesy of Dr. Maylyn Martinez.
DR. STERN: Thank you. [upbeat outro music] [upbeat outro music fading]