Undifferentiated Fatigue — Viva Defence

Long case viva — multifactorial fatigue

Candidate's opening statement (SASPOP)

"Doctor, my patient is Mrs MA, a 62-year-old woman with type 2 diabetes, hypothyroidism and obesity who works part-time as an administrative officer and who presents with a 3-month history of worsening fatigue that now limits her work and her self-care. She has multiple contributors: the uncontrolled diabetes with an HbA1c of 74, the iron deficiency with a ferritin of 18, the under-treated hypothyroidism, the uncontrolled obstructive sleep apnoea, the deconditioning, the beta-blockade, and a positive PHQ-2 of 5 suggesting a likely comorbid depression. Her problems are: the multifactorial fatigue; the uncontrolled type 2 diabetes; the iron deficiency; the under-treated hypothyroidism; the obstructive sleep apnoea; the likely depression; and the polypharmacy." ^[1]

Problem list

1. Multifactorial fatigue — physiological, physical and psychological contributors.
2. Uncontrolled type 2 diabetes (HbA1c 74 mmol per mol) — osmotic fatigue and deconditioning.
3. Iron deficiency (ferritin 18 micrograms per litre) — with the investigation of the underlying cause pending.
4. Under-treated hypothyroidism — the TSH to be confirmed and the levothyroxine optimised.
5. Obstructive sleep apnoea (STOP-Bang 5) — uncontrolled, the CPAP adherence to be assessed.
6. Likely comorbid depression (PHQ-2 of 5) — the full assessment and the treatment pending.
7. Polypharmacy — the beta-blocker and the statin as the contributory drugs. ^[1]

Integrated management plan

The principle: treat each contributor, validate the symptom, and avoid the single-cause anchoring. The fatigue is multifactorial, and the integrated management is the addressing of each contributor in turn. ^[1]

Investigations — the targeted Tier 2. Confirm the TSH and the free T4. Confirm the HbA1c and the renal function. Perform the coeliac screen (the tissue transglutaminase IgA with the total IgA) given the iron deficiency. Review the iron studies and commence the oral iron. Assess the CPAP adherence and the data download, and consider the repeat polysomnogram if the adherence is poor. Perform the full mood assessment (the PHQ-9) given the positive PHQ-2. Consider the polysomnogram if the sleep apnoea is unconfirmed. ^[1]

The diabetes. Optimise the glycaemic control — the individualised HbA1c target (typically 53 to 64 mmol per mol in this older patient with the comorbidity), the review of the current regimen, the addition of the SGLT2 inhibitor (which also benefits the heart failure and the weight) or the GLP-1 receptor agonist (which benefits the weight), the lifestyle intervention, and the cardiovascular risk reduction. The osmotic fatigue will improve as the glycaemic control improves. ^[1]

The iron deficiency. Commence the oral ferrous sulfate (65 to 100 mg elemental iron daily or on alternate days, with the vitamin C), reassess the haemoglobin and the ferritin at 4 weeks, and investigate the underlying cause — the gastrointestinal work-up (the faecal immunochemical test, the gastroscopy and the colonoscopy) given the age and the iron deficiency, and the gynaecological review if applicable. ^[1]

The hypothyroidism. Confirm the TSH, optimise the levothyroxine (the dose adjustment, the 6-week reassessment), and counsel the patient on the empty-stomach dosing and the drug interactions (the calcium, the iron, the proton pump inhibitor). ^[1]

The sleep apnoea. Assess the CPAP adherence and the symptom control; if the adherence is poor, the mask refit, the pressure adjustment, and the behavioural support. The weight loss and the exercise. The avoidance of the alcohol and the sedatives. ^[1]

The depression. The full PHQ-9 and the suicide risk assessment. The evidence-based treatment — the CBT and the SSRI (the sertraline as the first-line, with the 4 to 6 week onset), the addressing of the psychosocial stressors. ^[1]

The medication review. Consider the beta-blocker dose reduction or the switch (if the indication allows), and the statin holiday if the muscle symptoms are prominent (with the rechallenge at the lower dose or the different statin). ^[1]

The communication and the shared decision-making. Explain the multifactorial nature of the fatigue, the prioritisation of the management (the diabetes, the iron, the thyroid, the sleep, the mood, the medication), the realistic timeline (the improvement over weeks to months), the red flags to report, and the planned review. ^[1]

Examiner probing questions

Examiner: "Why is the PHQ-2 score of 5 not a diagnosis of depression?" The PHQ-2 is a screening tool, not a diagnostic instrument. A score of 3 or more has a sensitivity of 83 per cent and a specificity of 92 per cent for the major depressive disorder, per Kroenke. The positive screen is the prompt to the full diagnostic assessment — the DSM-5 criteria, the duration, the severity, the functional impairment, the bipolar exclusion, and the suicide risk assessment. The registrar who prescribes the antidepressant on the basis of the PHQ-2 alone has not performed the proper assessment. ^[1]

Examiner: "How do you explain the fatigue to this patient without dismissing her?" I validate the fatigue as a real and disabling symptom with multiple identifiable contributors. I explain that the diabetes, the iron deficiency, the thyroid, the sleep apnoea and the mood each contribute, and that the addressing of each in turn will improve the fatigue over weeks to months. I set the realistic expectation, I offer the clear plan, and I arrange the planned review. The patient who feels heard and who has a plan is far less likely to re-present or to seek the alternative-medicine pathway. ^[1]

Examiner: "What is the single most important safety assessment at this visit?" The suicide risk assessment — given the positive PHQ-2 and the depression. The registrar asks directly about the suicidal ideation, the intent, the plan and the means, and acts on the finding. The safety assessment is mandatory at every visit with the suspected depression. ^[1]