Fatigue

Causes:

• Anemia
• Chronic CCF
• Chronic infections such as tuberculosis, endocarditis etc
• Connective tissue disorders
• Metabolic states- Uremia, chronic liver disease
• Endocrine- hyperthyroidism, hypothyroidism, Addison disease, diabetes mellitus
• Malnutrition, starvation
• Electrolyte disturbances- Hyponatremia, hypokalemia, hypercalcemia, hypocalcemia, hypoglycemia
• Persistent chronic pain
• Chronic neurological disorders- Myasthenia, Parkinsonism
• Drugs- Sedatives, antipsychotics, barbiturates, beta blockers etc
• Alcoholism
• Underlying malignancy
• Steroid withdrawal
• Psychogenic- Continued unhappiness, overwork, lack of sleep, anxiety, depression

Investigations:

• CBC, RFT, electrolytes, LFT, TFT, FBS, PPBS, HIV, HBsAg, HCV
• Chest X Ray
• Further testing based on differential diagnosis

Treatment:

• Treatment of cause

Anorexia and Cachexia

Causes: 

• Malignancy
• Dysphagia
• Odynophagia
• Infections
• Medication side effects: Doxorubicin, cyclophosphamide, antibiotics etc
• Radiation
• Hepatitis
• Psychogenic

Pathogenesis: Cachexia occurs by following mechanisms

• Release of cytokines (TNF alpha, IFN gamma, Leukemia inhibitory factor, IL1, IL6)
• Increased glucose uptake by tumor
• Imbalance between rate of protein synthesis and degradation (due to proteolysis inducing factor)
• Decreased adipose tissue due to lipid mobilizing factor

Treatment:

• Eliminate all dietary restrictions. Give patient what he likes.
• Short course of low dose steroids
  • Dexamethasone 2mg OD
  • If longer treatment is anticipated- Megestrol- 200mg- PO- TDS

Edema

Causes:

• Unilateral/Localized:
  • Trauma- Bruises, sprain, fracture
  • Local irritants- Chemicals, thermal injury, stinges
  • Infections- Cellulitis, erysipelas, carbuncle, clostridial infection
  • Lymphatic obstruction- Filariasis, post surgery, radiation, Milroy disease
  • Others: Gout, deep vein thrombosis
• Bilateral:
  • Congestive- Cardiac failure, pericardial effusion, restrictive pericarditis, venous obstruction (thrombosis/from outside- Mass/gravid uterus), prolonged immobility
  • Renal- Acute glomerulonephritis, nephrotic syndrome, renal failure
  • Severe anemia
  • Nutritional deficiency- Hypoproteinemia (Albumin- <2.5), beriberi
  • Drugs- Nifedipine, OC pills, NSAIDs,
  • Others: Cirrhosis, angioneurotic edema, myxedema, premenstrual edema

Investigations (for bilateral)

• CBC, LFT, RFT, TFT
• Urine routine
• USG abdomen
• 2 D Echo
• Further tests based on differential diagnosis

Symptomatic treatment

• Tab. Lasilactone (Frusemide 20mg + Spironolactone- 50mg)- 1-1-0