PEARLS                  Additional Information about fatigue  

This is not a case study, just write about fatigue and the most pertinent things to know about fatigue and how to make diagnosing easier. You can use highlighted areas as your guide and you can be brief.

Chief Compliant

1. History of Present Illness
2. Past Medical History
3. Family HistMust post first.How to Do Well in Discussions

   Make your initial post responding to the above questions by Saturday, and comment on at least four of your classmates’ posts by Tuesday. Posting late may lose you points.
   Respond to the specific questions posed in the discussion.
   Be sure to base your initial post and responses on course materials, and use 7th ed. APA citations in every post.
   Post your responses over three days and respond to four or more students to receive full credit for frequency of participation.
   Write clearly and proofread; errors can lose you points.
   Quality of posts, citations, frequency, and timeliness of posts all factor into your discussion grade. See the Participation Grading Rubric for details.

   Instructions:

   Week 5 Discussion

   Please read the Wells Fargo Case at

   http://ezproxy.umgc.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=131840330&site=eds-live&scope=site

   You have just been named the new CEO at Wells Fargo.  The facts cited in the above case reflect the reality of the situation you have just inherited.  You are concerned about all the practices you find but want to prioritize your efforts.

   What are the three practices that you assign the highest priority?
   How would you address these three practices?
   Looking at the big picture, what about Wells Fargo’s corporate culture is encouraging these practices and how would change the overall corporate culture to discourage them?

   In answering the above, ignore the legal issues involved in the case and focus from the perspective of ethics.

   You must start a thread before you can read and reply to other threads

   Must post first.

   How to Do Well in Discussions

   Make your initial post responding to the above questions by Saturday, and comment on at least four of your classmates’ posts by Tuesday. Posting late may lose you points.
   Respond to the specific questions posed in the discussion.
   Be sure to base your initial post and responses on course materials, and use 7th ed. APA citations in every post.
   Post your responses over three days and respond to four or more students to receive full credit for frequency of participation.
   Write clearly and proofread; errors can lose you points.
   Quality of posts, citations, frequency, and timeliness of posts all factor into your discussion grade. See the Participation Grading Rubric for details.

   Instructions:

   Week 5 Discussion

   Please read the Wells Fargo Case at

   http://ezproxy.umgc.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=131840330&site=eds-live&scope=site

   You have just been named the new CEO at Wells Fargo.  The facts cited in the above case reflect the reality of the situation you have just inherited.  You are concerned about all the practices you find but want to prioritize your efforts.

   What are the three practices that you assign the highest priority?
   How would you address these three practices?
   Looking at the big picture, what about Wells Fargo’s corporate culture is encouraging these practices and how would change the overall corporate culture to discourage them?

   In answering the above, ignore the legal issues involved in the case and focus from the perspective of ethics.

   You must start a thread before you can read and reply to other threads

   ory

4. Social History
5. Medication History
6. Allergies
7. Review of Systems
8. Physical Exam
9. Diagnostic Tests (recommended or already done)
10. Diagnosis and Differential Diagnosis (at least 4)
11. Management Plan (using applicable guidelines)
12. Case Summary and Reflection

Differentiate Fatigue

What is in the Differential Diagnosis of Fatigue? | Pediatric Case and Reference Article | Pediatric Education

WHAT’S THE CONNECTION BETWEEN COVID-19 AND PERSISTENT FATIGUE?

Fatigue

ARE WOMEN AT HIGHER RISK OF COVID-19 VACCINE-RELATED ADVERSE EVENTS?

April 9, 2021FA Manian MD, MPHAdaptive immunity;, Adverse events, Anaphylactic reaction, Anaphylactoid reaction;, CDC;, Covid-19 vaccine, Cytokines, Dendritic cells;, Dizziness, Fatigue;, Female;, Headache;, Humoral immunity, Immunity;, Infections;, Innate immunity;, Male;, Men;, Microbiome;, Moderna, MRNA;, Pfizer, Sex differences, Women;, X chromosome, Y chromosome

Data to date shows a preponderance of Covid-19 vaccine-related adverse events (AEs) among women compared to men. This finding may be due to the generally more robust immunological response to infections and vaccines among women, increased reporting of AEs by women, genetic factors, microbiome differences as well as other factors.^1-3

A CDC study involving mRNA vaccines (Pfizer and Moderna) during the 1^st month of vaccination roll out in the US, found that nearly 80% of adverse events were reported by women.  The great majority (>90%) of these AEs were not serious and included symptoms such as headache, dizziness and fatigue.¹

A JAMA study involving individuals receiving one of the mRNA vaccines found that 94% (Pfizer) and 100% (Moderna) of anaphylaxis events occurred among women. Of note, the median age was ~40 years  with the majority of anaphylaxis events were reported after the first dose. ²

Higher incidence of AEs following Covid-19 vaccination is not surprising and may be explained biologically. Women typically have a more robust immune response to infections and vaccination, both at the level of innate and adaptive immunity with higher antibody responses.  

These findings may be in part due to hormones such as estrogen which is known to enhance differentiation of dendritic cells and proinflammatory cytokine production. Other proposed mechanisms include differences in microbiome between sexes and sex-based genetic influences on humoral immune profile with the X chromosome expressing 10 times more genes than the Y chromosome, including genes that influence immunity.³

Bonus Pearl: Did you know that anaphylactic reaction to the mRNA Covid-19 vaccines is extremely rare, occurring in only 2-5 cases/ million!²

January 10, 2021FA Manian MD, MPHChronic fatigue syndrome, Covid-19, Covid-19;, CRP, EBV;, Enterovirus;, Fatigue;, Influenza, Influenza;, Intereukin-6;, SARS-CoV-1, SARS-CoV-2;

Fatigue is one of the most common symptoms in patients with Covid-19, both during the acute illness as well during the weeks or months that follows it. Depending on the study, fatigue has been reported in around 30%-80% of patients at 2-3 weeks to 6 months or longer after the onset of illness (1-4).

In a study of hospitalized patients with Covid-19, ~80% of patients complained of fatigue during the acute illness, with ~50% having persistent fatigue at a mean follow-up of 60 days following onset of illness (1). Persistent fatigue was the most common symptom during the post-Covid-19 period, followed by dyspnea, joint pain, chest pain and cough.

In another study, 52.3% of patients with Covid-19 complained of persistent debilitating fatigue at a median of 10 weeks after initial onset of symptoms, despite a negative test for the virus (2). Of interest, there was no association between severity of Covid-19 illness/need for hospitalization and post-covid fatigue.  No association was found between routine laboratory markers of inflammation, WBC profile, LDH, C-reactive protein or interleukin-6 levels and persistent fatigue.

A CDC survey of outpatients with Covid-19 patients at 14-21 days from test date found persistent fatigue in one-third of patients (3).   

A MedRxive study (pending peer review) of over 3700 patients with definite (27%) or probable diagnosis of Covid-19 from 56 countries (>90% not hospitalized) reported fatigue in 78% of patients after 6 months (4).

Although the true nature or course of persistent fatigue following Covid-19 has yet to be clearly defined, In some respects, it’s reminiscent of chronic fatigue syndrome associated with many acute viral infections, such as SARS, EBV, and enteroviruses (5-7).

Bonus pearl: Did you know that persistent fatigue following Covid-19 may be more frequent than that following influenza in which >90% of outpatients recover within about 2 weeks (3)?

Website:  Fatigue; – Pearls4Peers

Chronic Fatigue

by Lucinda Bateman, M.D.
Fatigue Consultation Clinic

Recently I was talking to the nurse practitioner I just hired to work in my fatigue clinic. Bemoaning a transient feeling of burnout, I groaned, “I am so tired of slow scientific progress and of not being able to help my CFS patients.” Having worked in the clinic for almost three months—an immersion training in complex chronic illness that’s been challenging yet revelatory—my nurse practitioner smiled as she said, “I hear you, but I don’t agree that there is nothing that helps. Again and again, as I’ve become familiar with CFS patients and their condition, they’ve said to me, ‘You may think this sounds bad, but I’m so much better than I used to be!’”

This statement reminds me of what I already know but sometimes forget: there are many ways to improve the situation of patients with CFS, even if a cure is not yet within our reach. True, there is marked heterogeneity (variety and individual differences) within the large group of people meeting the CFS case definition. But when it comes to practical treatment advice, there are definitely some common truths or “pearls of wisdom” that seem to apply to almost everyone. The five pearls I’m about to share have been used to teach medical professionals a simple plan of chronic management for CFS patients. The plan provides a practical way to continually address CFS symptoms that on the surface may appear complicated or daunting. This advice can improve daily function, at least until science identifies biomarkers and develops treatments directed at the physiology of the illness.
Obviously this plan of support is best implemented after other causes of chronic fatigue and pain have been evaluated and excluded, such as major organ disease or failure, metastatic cancer, autoimmune disease, severe eating disorders, substance abuse or mental illness. I mention this because epidemiology studies have shown that many patients debilitated by chronic fatigue have not consulted with a physician at all and, once properly evaluated, were sometimes found to have other more treatable illnesses.
The following pearls of wisdom aren’t listed in any particular order. I’ve found them all to be greatly helpful in managing CFS patient care. Hopefully they’ll help you identify areas you and your health care team can explore.

Pearl 1: Build emotional resilience

From day one of a CFS diagnosis, it’s bad news. People around an individual with CFS may not understand the illness, how it feels or what to do about it. At first a CFS patient might receive attention, but as months go by without the kind of physical improvement people expect, those who once offered support may disappear. The ongoing physical limitations are accompanied by ongoing emotional trials. An acute illness is definitely traumatic, but most can muster a good fight while actively seeking a diagnosis and some type of rescue care. It’s living with the “C” in CFS that really gets old. (Editor’s note: see “Trauma & CFS,” page 10.)

CFS can be especially punishing compared to other chronic illness. Because the symptoms are difficult to measure or prove clinically, they may be met with doubt or disapproval by those whose support is needed most. Because CFS follows a relapsing and remitting pattern, in addition to feeling limited most of the time, patients can’t predict when they’ll feel even moderately better or worse.
Because of the characteristic postexertional symptoms of CFS, an honest effort to function or simply have a little fun is often punished mercilessly by a relapse of pain, fatigue and brain fog. There are innumerable personal losses in the present and potential losses projected far into the future. Focusing on the loss can lead to a downward spiral thatcan impact life in very tangible ways.
In order to thrive, anyone living with CFS must repeatedly rejuvenate the will to live and to find joy in living, even while chronically ill. It can be done! No one and no disease can take away the freedom to choose how to respond to a difficult situation.
Two very important roles I play every day for my patients in the clinic are to be a strong advocate and to be a cheerleader when the going gets tough. I do this because the patients who do best over the long term are those who build their emotional resilience. They develop insight. They learn how to get out of an emotional slump or calm paralyzing fears. They learn to get back up and take one step forward. They cultivate the resources needed—among family, friends, counselors and medical providers—to stay as positive as possible. Anything I can do to support this is valuable to care.

Pearl 2: Achieve the most restorative sleep possible

Universally I’ve heard from patients that the better they sleep, the better they feel and function. The trick is figuring out how to accomplish this, and the solutions definitely vary by patient. Improved sleep immediately helps not only fatigue, but pain as well, and it probably improves cognition, mood, headaches and immune function to some degree. Natural sleep is always best, but the unfortunate fact is that most CFS patients struggle with chronically disrupted and unrefreshing sleep that’s not easily fixed. There is no doubt that left untreated, even for a few days, sleep disruption worsens most aspects of CFS. (Editor’s note: see “The Biology of

Sleep,” page 7.)
Unfortunately there’s no perfect remedy for sleep. Practicing good sleep hygiene—such as consistent bedtimes and reducing caffeine intake—is imperative, but often not enough. Even the best of medications used for sleep have modest success, and some may even have adverse effects that can actually make sleep less restorative.
Sleep medications may change the architecture of sleep, alter daytime cognition or worsen fatigue, so they should be used in the lowest effective doses and, as much as possible, directed at the cause(s) of sleep disturbance. It may be useful to undergo polysomnography (a sleep study) if single drugs or low doses are ineffective.
If medication is necessary, it may be helpful for your health care professional to choose one that also treats other symptoms you may have. For example, while primarily improving sleep, drugs like Lyrica (pregabalin) or Neurontin (gabapentin) may reduce pain, and Elavil (amitriptyline) may keep IBS symptoms in check.
Achieving restorative sleep is an ongoing mission, but one well worth the attention.

Pearl 3: Achieve reasonable pain control

Unrelenting or severe pain is physically and mentally exhausting; it disrupts sleep,worsens mood and prevents physical activity. These are all important reasons to work on reasonable pain control. I say “reasonable” because it may be impractical to eliminate pain completely, so the goal is to push pain into the background, to feel more in control and less frightened by the pain. This can be done by both reducing the pain and by learning to manage pain psychologically.

The first areas to consider when pain escalates are related to sleep, emotion and physical activity. Remember that
restorative sleep improves generalized pain. It’s also important to note that emotional distress such as fear, depression, guilt or grief can dramatically escalate pain and reduce pain tolerance. With CFS in particular, overextending physically, such as attempting vigorous or prolonged exercise, can raise pain levels both immediately and for days afterward. Inactivity, such as staying in bed too long, can also increase stiffness and overall achiness. So when pain increases, first reexamine sleep quality, emotional health and physical activity.
The decision to use pain medications, intermittently or persistently, should be made carefully with a qualified medical professional and adapted to each individual situation. Always be sure that appropriate investigations have been done to understand the cause and/or nature of the pain, so that treatment can be directed and maximally effective. Some focal pain conditions can be treated very effectively with high-tech procedures. Fortunately there are a growing number of effective pain-modulating drugs for the broad spectrum of conditions that can cause pain. Finding the right medication for your system and specific type of pain is key.
The goal is to keep pain in reasonable control with thoughtful prevention and treatment, and to seek more intensive treatment from a specialist when this is difficult to accomplish.

Pearl 4: Balance physical pacing with physical conditioning

Perhaps the most important fact I’ve learned from thousands of hours treating patients with CFS is that the most effective intervention for CFS is learning to control the type, duration and intensity of activity to avoid a “crash” or relapse. This is called pacing, or avoiding the push-crash cycle, and it works. Every patient should become familiar with his or her own threshold of relapse, even when it seems like a moving target, and learn to avoid triggering relapse symptoms by keeping activity within a safe level.

On the opposite end of the spectrum, activity limitation can cause diminished strength of both the skeletal muscles and the heart muscle. Without enough use, these muscles actually atrophy, getting smaller and weaker as time goes on. This global decline in strength and stamina is called physical deconditioning, and unfortunately it’s often accompanied by weight gain as well. Being deconditioned can worsen pain, fatigue, balance/stability, orthostatic intolerance and sleep, not to mention self esteem. A thorny problem, deconditioning is not easily repaired because initial attempts to exercise invariably result in a flare-up or relapse of CFS symptoms.
These factors make both pacing and physical conditioning important for people with CFS. The objective is to carefully and regularly engage in a controlled level of physical rehabilitation that won’t trigger relapse symptoms. The trick is figuring out how to do it—and especially how to adapt to a changing threshold of relapse. Tolerance for stretching, strengthening and cardiovascular exercise varies widely among patients with CFS. It’s helpful to start with these guidelines: short duration (five minutes), low intensity (not strenuous), adequate rest/recovery periods (even a day or more) and utilization of a position (reclining or in water) that won’t worsen orthostatic intolerance if that’s an issue.
The process of learning to effectively pace activity while still minimizing deconditioning can be a frustrating challenge, but it’s an effective and self-empowering tool when it can be accomplished.

Pearl 5: Identify and treat comorbid conditions

There are a number of medical conditions, often subtle in presentation, that frequently overlap or occur in combination (are comorbid) with CFS. These conditions have well known diagnostic and treatment plans that a medical professional can follow whether familiar with CFS or not. Since each untreated condition may worsen CFS symptoms, any improvement in symptoms of comorbid conditions is progress in reducing the severity of CFS.

Here are some of the more common comorbid conditions present in people with CFS:

• Sleep disorders (such as obstructive or central sleep apnea; restless legs syndrome, periodic limb movement or myoclonus; excessive sleepiness)
• Allergies, chronic sinusitis and reactive airway disease (asthma)
• Irritable bowel syndrome (IBS), reflux and heartburn (GERD), lactose intolerance, celiac disease
• Focal pain conditions such as osteoarthritis, cervical or lumbar disc disease
• Primary or secondary mental health conditions (such as attention deficit disorders, depression, anxiety)
• Metabolic syndrome (primary or secondary) and type II diabetes
• Hormone imbalances or dysregulation (such as menopause, low testosterone, hypothyroidism, polycystic ovarian syndrome)
• Chronic or recurrent infections (such as herpes or shingles outbreaks)
• Vitamin D and vitamin B12 deficiency or “low normal” values

People with CFS should learn about their own comorbid conditions, and in partnership with a medical professional, see that they get the best supportive treatment available.

Wisdom applied

The relevance of these clinical pearls of wisdom depends on the features of each individual’s illness, but I’ve seen them all benefit CFS patients by improving functionality and quality of life. With a chronic condition like CFS, this can go a long way toward helping patients manage their illness while we search for targeted interventionsand ultimately a cure.

Resources:

Website:  Pearls of Wisdom from a CFS Physician (ei-resource.org)

Web site: Fatigue: Causes, Diagnosis, Treatment & More (healthline.com)

Web site:  Evaluation of fatigue – Differential diagnosis of symptoms | BMJ Best Practice US

Fatigue: An Overview website: Fatigue: An Overview (aafp.org)

Website: 6 Reasons Why You’re Always Tired and How to Fight It (aarp.org)