Download Chronic fatigue syndrome

Fatique

Fatigue refers to a sensation of exhaustion
during or after usual activities, or a feeling
of inadequate energy to begin these
activities. It should be distinguished from
somnolence, dyspnea, and weakness,
although these symptoms often are
associated with fatigue.
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Fatigue may be divided into three
categories based upon the duration
of symptoms:
1- Recent fatigue refers to symptoms lasting less
than one month
2- Prolonged fatigue refers to symptoms
lasting for more than one month
3- Chronic fatigue refers to symptoms lasting
over six months, but does not necessarily imply
the presence of the chronic fatigue syndrome
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Chronic fatigue syndrome
The chronic fatigue syndrome is an uncommon
cause of chronic fatigue, although it is important
to make the distinction between the two entities.
The revised Centers for Disease Control
definition of chronic fatigue syndrome states
that patients must have clinically evaluated,
unexplained, persistent or relapsing fatigue plus
four or more specifically defined associated
symptoms. In contrast, chronic fatigue itself is
simply defined by the presence of fatigue for
longer than six months.
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Idiopathic chronic fatigue
Fatigue for which no medical or psychiatric
explanation can be found is seen in 8.5 to 34
percent of patients with this complaint. If the
fatigue persists for over six months and is
debilitating but does not meet criteria for the
chronic fatigue syndrome, it is termed idiopathic
or nonspecific chronic fatigue. The disability
rates and health care utilization in these patients
is similar to those with chronic fatigue
syndrome. Idiopathic chronic fatigue may
represent part of the spectrum of a continuum
of illness that includes the chronic fatigue
syndrome.
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History

Fatigue that is due to an underlying
medical or psychiatric disorder usually
presents as one of several reported
symptoms. A specific cause for fatigue is
found less frequently when fatigue itself is
the principal concern with few or no other
symptoms.
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The clinician should rely upon openended questions, encouraging the patient
to describe the fatigue in his or her own
words. Questions and comments such as
"What do you mean by fatigue?" or
"Please describe what you mean" may
elicit responses which suggest a
generalized sense of tiredness that help
distinguish fatigue from dyspnea,
somnolence, and true weakness.
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Patients with organ-based medical
illness often associate their fatigue
with activities they are unable to
complete. In contrast, patients with
fatigue that is not organ-based are
tired all the time; their fatigue is not
necessarily related to exertion, nor
does it improve with rest.
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The impact and duration of fatigue
should be assessed to determine
whether further history and
evaluation should focus upon the
fatigue itself, or whether the fatigue
should simply be noted but not
explored directly (at least not at the
first visit).
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Fatigue of recent onset may be shortlived, while fatigue that lasts six months
may represent a chronic and potentially
debilitating illness. The clinician should
determine the extent to which the
patient's fatigue interferes with work,
family, or activities of daily living, and
what changes in lifestyle the patient has
made in response to his or her fatigue.
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The history should include questions
screening for psychiatric disorders
(particularly depression, anxiety
disorders, somatization disorders, and
substance abuse) early in the
evaluation of the fatigued patient in
view of the strong relationship
between chronic fatigue and
psychiatric illness described above
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There is a general perception
among practitioners that
patients who complain of chronic
fatigue are reluctant to accept a
psychologic explanation for their
symptoms. However, up to twothirds of patients with fatigue,
when asked, will acknowledge a
psychosocial contribution to this
symptom
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The quantity and quality of the
patient's sleep should be assessed to
determine whether or not sleep
improves the patient's symptoms.
Such improvement may suggest a
primary sleep disorder or disturbed
sleep as an etiology for the patient's
fatigue.
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A thorough evaluation of medications,
both prescribed and over the counter,
should be undertaken. Recreational
drug use, including alcohol, should be
carefully explored in any patient with
fatigue.
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Physical examination

A complete physical examination is important to
exclude some specific causes of fatigue. The
physical examination also helps to establish the
doctor-patient relationship, letting the patient
know that his or her complaint is being taken
seriously and is worth investigating.
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The general appearance of the
patient should be considered for
possible signs of a psychiatric
disorder such as a diminished
level of alertness, psychomotor
agitation or retardation, and poor
grooming.
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A thorough evaluation for
lymphadenopathy, a possible sign
of chronic infection or
malignancy, should be performed.
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Pallor, tachycardia, and a
systolic ejection murmur may
suggest anemia.
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Evidence of thyroid disease
should be sought, including a
goiter or thyroid nodule,
ophthalmologic changes, and
delayed deep tendon reflexes.
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The cardiopulmonary
examination should focus upon
detecting signs of congestive
heart failure and chronic lung
disease, both important causes of
fatigue.
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A complete neurologic
examination is warranted,
including assessment of muscle
bulk, tone and strength,
abnormalities which would
suggest a neuromuscular disorder
to account for the patient's
fatigue.
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Laboratory studies

Laboratory evaluations in the absence of a
positive history or physical examination are of
little diagnostic utility in the evaluation of the
fatigued patient
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1-complete blood count with
differential
2-erythrocyte sedimentation rate
3-chemistry screen including liver
function tests and measurement of
serum creatine kinase, calcium, and
thyroid stimulating hormone (TSH).
4-HIV testing
5-PPD placement
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In menstruating women, it may
be appropriate to check iron
studies even in the absence of
anemia since treatment with iron
has been found to help some
women with a normal hemoglobin
but low serum ferritin
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Screening examinations
appropriate for the age and sex
of the patient, such as
mammography and
sigmoidoscopy, should be
performed at some point during
the evaluation.
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weakness
The evaluation of the patient presenting with a
complaint of "weakness" involves three steps
1-Distinguishing true muscle weakness from
functional motor impairment not due to loss of
muscle power

2- Localizing the site of the lesion within the
neuromuscular system that is producing
weakness
3- Determining the cause of the lesion
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DISTINGUISHING TRUE MUSCLE
WEAKNESS FROM FUNCTIONAL
WEAKNESS

Many patients who complain of weakness
are not objectively weak when muscle
strength is formally tested. A careful
history and physical examination will
permit the distinction between functional
disease and true weakness.
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History

A variety of systemic disorders can induce the functional
symptom of weakness. Included in this group are
cardiopulmonary disease, joint disease, anemia, cachexia
from malignancy or chronic infectious or inflammatory
disease, depression, deconditioning, neuropathies, and
demyelinating diseases. Therefore, the possibility of
functional weakness should be considered in a patient
known to have any of these conditions. Furthermore,
careful questioning will reveal that the patient is limited
by shortness of breath, chest pain, joint pain, fatigue,
poor exercise tolerance, paresthesias, or spasticity rather
than a true decrease in muscle power.
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
Patients with functional disease usually
complain that they are weak. In comparison,
those with true muscle weakness typically
complain that they are unable to perform
specific tasks, such as climbing stairs or
combing hair, or that they have a feeling of
"heaviness" or "stiffness" in their limbs. Muscle
pain is uncommon with true weakness, but is
often a problem for patients with overexertion,
cramps, or fibromyalgia
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Physical examination

As with the history, the physical
examination should include a careful
search for one of the disorders that can
cause functional weakness as well as
testing of muscle strength. In addition,
two general observations may be helpful:
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Muscle strength is preserved in
patients with cachexia despite
advanced generalized muscle
atrophy. In contrast, patients with
true muscle weakness due to a
myopathy generally have normal
muscle bulk at the time of
presentation.
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Muscle tenderness is usually not
associated with one of the causes of
true muscle weakness. There are,
however, exceptions to this general
rule including infectious myopathies
such as trichinosis and viral myositis,
certain drug-induced myopathies,
thyroid myopathy, and the inherited
metabolic myopathies.
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True muscle weakness is documented by
formal muscle testing. The strength of
each muscle can be assessed by
determining how much force is required
by the examiner to overcome maximal
contraction by the patient. A widely used
system to measure muscle strength is the
grading system from the Medical
Research Council which is based upon a
scale of zero to five
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
Zero — no contraction
One — flicker or trace of contraction
Two — muscle contraction possible only
with gravity eliminated
Three — muscle contraction against
gravity only
Four — power decreased but muscle
contraction possible against resistance
Five — normal power resistance
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