Pediatric Primary Care Case Studies (16 page)

4. The primary care provider needs to be a part of the team, including visiting with the school personnel, attending a team meeting, and following up both with the healthcare and the total management plan to get the child back into school and functioning in a happy and healthy way.

REFERENCES

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Chapter 5

An Adolescent with Fatigue

Dawn Lee Garzon

Fatigue is one of the most common adolescent complaints in primary care settings. A number of medical, behavioral, and psychosocial factors can produce this subjective complaint; therefore, pediatric healthcare providers must be able to differentiate among common causes of fatigue and determine the need for medical intervention for adolescents with this complaint.

Educational Objectives

1.   Consider adolescent development issues affecting both the diagnosis and treatment of fatigue.

2.   Describe the lifestyle factors that affect the incidence of adolescent fatigue.

3.   Describe the objective and subjective findings needed to establish a differential diagnosis in an adolescent with fatigue.

4.   Formulate a tailored plan of care to manage an adolescent with fatigue.

   Case Presentation and Discussion

Jennifer Styles is a 17-year-old who presents to your office with a complaint of “being tired all the time.” Jennifer admits that her fatigue has worsened significantly over the summer and is worried that she won’t make it through the day once school starts in a few weeks. She reports that she has two summer jobs, one at the community pool as a lifeguard and one where she helps babysit two school-age children. Jennifer is not accompanied by anyone else, but she says she can call her mother on the cell phone if “anyone needs her.” “But,” she tells you, “my mom thinks I have mono.”

What are the most common causes of fatigue in adolescents?

Fatigue as a Symptom

Fatigue is a common somatic complaint that often presents with other symptoms like sleepiness, altered ability to focus, irritability, and weakness. By definition, fatigue is a sense of abnormal or excessive tiredness that results in a need for rest and results in an impaired ability to perform normal activities. It is one of the most common complaints in pediatrics and is especially prevalent
during adolescence. Most teenagers complain of “being tired” at one time or another, and parents often complain that their adolescents seem exhausted or have very low energy. National studies show that 67% of adolescent females in 6th through 10th grade complain of morning fatigue at least once a week (Ghandour, Overpeck, Huang, Kogan, & Scheidt, 2004). The challenge of this condition is that fatigue can result from a self-limiting situation like staying up all night studying for final examinations, be a symptom of a mental illness like depression, or indicate the presence of a significant medical condition like anemia or cardiomyopathy.

Pathophysiology

There are multiple conditions that cause fatigue. It is the normal result of physical exertion or energy use that exceeds the body’s normal capacity (Ozuah & Sigler, 2001). Physiologic reasons for fatigue appear when the level of cellular metabolic need is greater than the cell’s adenosine triphosphate (ATP) stores, the body’s glucose or glycogen stores are depleted, metabolism is altered, or cerebral oxygenation is compromised. Busy school schedules, participation in extracurricular activities, inadequate sleep, inadequate caloric intake, substance use/abuse, and dysfunctional sleep patterns can all result in abnormally tired teens.

Many adolescents with fatigue experience symptoms as an abrupt complaint following an acute infection (Carter, Kronenberger, Edwards, Michalczyk, & Marshall, 1996). However, postinfectious fatigue can last for weeks to years. Illnesses that are known to cause fatigue include acute and chronic Epstein-Barr infection, cytomegalovirus, herpesvirus, human immunodeficiency virus (HIV), histoplasmosis,
Mycoplasma
pneumonia, toxoplasmosis, tuberculosis, rheumatoid arthritis, diabetes mellitus, cancer, Lyme disease, and hepatitis (Feins, 1999; Ozuah & Sigler, 2001; Tunnessen & Roberts, 1999).

Fatigue can also be a response to stress and is considered a symptom of depression.

Cultural Influences of Fatigue

Culture shapes and influences how individuals experience health symptoms and whether or not they seek medical attention. Fatigue is a universal human complaint and, therefore, occurs in all populations; however, there are some significant cultural variations that are worth noting. Some cultures value achievement and activity or “doing,” whereas others value just “being” (Giger & Davidhizer, 2004). Individuals from “doing” cultures may be less tolerant of fatigue symptoms and, therefore, are more likely to present to healthcare providers for treatment (Lubkin & Larsen, 2005; Ware & Kleinman, 1992). The belief that altered energy states should be treated to increase energy is also important. There are many homeopathic and complementary medical treatments used to combat fatigue that range from the use of herbal medications
and dietary modification to guided imagery, meditation, and cognitive behavioral therapy.

Ghandour and associates (2004) conducted a population-based investigation of 8,250 U.S. teens and found racial/ethnic variation in the report of morning fatigue. In this study, the authors found that non-Hispanic white and Hispanic adolescents reported morning fatigue at least one to three times a week at higher rates than their Asian, non-Hispanic black, and Native American peers (38.3% and 34.2% versus 31.2%, 30.8%, and 26.5%, respectively).

Adolescent Development Factors

Adolescence has traditionally been described as a time to achieve four major milestones—separation from parents, establishment of peer relationships, achievement of sexual identity, and establishment of vocational goals for adulthood. Many authors have further broken down this 7 year or more phase of human development into three subunits—early, middle, and late adolescence—because teens do not achieve the four major goals along parallel trajectories. Rather, early teens are characterized as working on issues of physical development and comfort with one’s sexually maturing body and emerging sexual interests and behaviors, whereas middle teens are working to achieve parental separation and peer relationships with the opposite sex, and late teens are focused on development of intimate relationships with the opposite sex (or a single partner) and vocational choices and plans. The average 17-year-old is transitioning from middle to late adolescence.