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 asthenia, motor impairment due to pain or joint dysfunction, and true weakness.
There is debate, however, whether depression in individual patients is the cause or consequence of symptoms of chronic fatigue.
The clinician should rely upon open-ended 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 that help distinguish fatigue from dyspnea, somnolence, and true weakness.
Age: people 60 years or older usually have an underlying cause for chronic fatigue, whereas in the 30 to 39 years age group the cause is more likely to be idiopathic chronic fatigue. Nationality: Residence in, or travel to, areas where certain infections are endemic (TB). Occupation: Occupational, recreational, and residential exposure to tick-infested woods or fields near woods (Lyme disease)
HPI: Duration (recent, prolonged, or chronic) Sudden or progressive onset (e.g., chronic fatigue syndrome is usually sudden-onset) Recovery period (e.g., the course of chronic fatigue syndrome is associated with intermittent periods of recovery lasting hours or days) Impact of rest (physiological versus non-physiological fatigue) Impact of physical activity or mental activity (e.g., chronic fatigue syndrome is typically exacerbated by relatively minor physical or mental activity) Level of physical activity (sedentary lifestyle is a cause of fatigue, and patients may benefit from exercise therapy) and concomitant presence of weakness (e.g., reduced muscle power at rest may point to a neuromuscular disorder) Seasonality and any current influenza outbreak (which occur most commonly in the winter).
P.M Hx and Family Hx : anaemia, chronic liver disease, hypothyroidism, psychiatric disorder. Drug Hx: Anti-arrhythmics, Antidepressants,Anti-emetics,Antiepileptics,Antihistamines,Antihypertensives,Corticosteroids,Diuretics Social Hx: Alcohol
Other: Other laboratory studies can be obtained based on history. ( Erythrocyte sedimentation rate can be considered in older patients who also have symptoms consistent with polymyalgia rheumatica or giant cell arteritis).
The doctor-patient relationship is of profound importance. Two-thirds of patients with CFS reported that they were dissatisfied with the quality of their medical care and felt their clinicians lacked communication skills and education regarding their diagnosis.
Brief regularly scheduled appointments can be used to monitor progress in these areas and are preferred to having the patient being seen on an "as needed" basis.
Antidepressants — A trial of antidepressant drugs should be offered to patients whose illness has features of depression, regardless of whether strict criteria for depression have been met. Patients should be advised that immediate response to antidepressant therapy is not expected, and that treatment for several weeks would be needed before their response could be assessed. Antidepressants may themselves provoke or exacerbate fatigue, however, and should be discontinued in patients who do not demonstrate symptom improvement within a reasonable time frame (six to eight weeks)
but cases in children have been recognized.
Approach to Fatigue
5thYear Medical Student
• A sensation of exhaustion during or after usual activities, or a feeling of
inadequate energy to begin these activities.
• Fatigue can be manifested as difficulty or inability initiating activity
(perception of generalized weakness); reduced capacity maintaining
activity (easy fatigability); and difficulty with concentration, memory,
and emotional stability (mental fatigue).
• Fatigue is defined as the subjective complaint of tiredness or diminished
energy level to the point of interfering with normal or usual activities.
Duration of fatigue can be:
• Recent (less than one month),
• Prolonged (more than one month)
• Chronic (over six months).
• The presence of chronic fatigue does not necessarily imply the
presence of the chronic fatigue syndrome, which is discussed
WHAT ISTHE DIFFERENCE
DYSPNEA AND MUSCLE
What is the difference between Fatigue,
dyspnea and muscle weakness ?
A subjective experience of breathing discomfort that is comprised of qualitatively
distinct sensations that vary in intensity.
A. Primary or true muscle weakness
B. Muscle tiredness (ASTHENIA)
• A major symptom
• Found in all populations and associated with multiple factors.
• It is one of the top 10 chief complaints leading to family practice office visits
• Fatigue occurs in up to 20% of patients seeking care
• Higher in women than in men.
• Psychiatric illness is present in 60 to 80 % of patients with chronic fatigue.
• The three major psychiatric illnesses were major depression (58 percent), panic
disorder (14 percent), and somatization disorder (10 percent).
What is the difference between the CFS,
chronic fatigue & idiopathic chronic fatigue?
chronic fatigue syndrome
(Based on CDC 2006)
Clinically evaluated, unexplained, persistent or relapsing fatigue.
that is of new or definite onset.
is not the result of ongoing exertion;
is not alleviated by rest;
Cause reduction in previous levels of occupational, educational, social,
or personal activities
chronic fatigue The presence of fatigue for longer than six months.
idiopathic chronic fatigue No medical or psychiatric explanation can be found .
persists for over six months and is debilitating.
but does not meet the criteria for the chronic fatigue syndrome.
• Physical examination
• Laboratory studies
• The history is the most important component of the evaluation of chronic fatigue.
• The physical examination and laboratory studies provide supporting data.
• Fatigue that is due to an underlying medical or psychiatric disorder usually presents
as one of several reported symptoms.
• The clinician should rely upon open-ended questions ?
• 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.
• ID: Age, Gender, Nationality, occupation.
o Onset - abrupt or gradual, related to event or illness?
o Course - stable, improving or worsening?
o Duration and daily pattern
o Factors that alleviate or exacerbate symptoms
o Impact on daily life - ability to work
o Accommodations that patient/family has made to adjust to fatigue symptoms
• P.M Hx. ??
• P.S Hx.
• Family Hx.
• Social Hx. ??
• Drug Hx. ???
• Allergy Hx.
• Systemic review
• General appearance: level of alertness, psychomotor agitation or retardation,
grooming (psychiatric disorder)
• Presence of lymphadenopathy: a possible sign of chronic infection or malignancy.
• Evidence of thyroid disease: goiter, thyroid nodule, ophthalmologic changes
• Cardiopulmonary examination: signs of congestive heart failure and chronic lung
• Neurologic examination: muscle bulk, tone, and strength; deep tendon reflexes;
sensory and cranial nerve evaluation
Specific clinical signs of organic disease associated with
fatigue include the following:
• Pallor, tachycardia, systolic ejection murmurs: anaemia
• Blue sclera: iron deficiency
• Jaundice, palmar erythema, Dupuytren's contracture: chronic liver disease
• Goitre or thyroid nodule, dry skin, delayed deep tendon reflexes, peri-orbital
puffiness, ophthalmological changes: hypothyroidism
• Weight loss, hyper-reflexia, tachycardia, atrial fibrillation, fine tremor, goitre:
• Hypotension, pigmentation in skin creases, scars, and buccal mucosa: Addison's
• Pulmonary stasis, elevated jugular venous pressure, ankle oedema: heart failure
• Reasonable initial laboratory studies to obtain
• Complete blood count with differential
• Chemistry screen (including electrolytes, glucose,
renal and liver function tests)
• Thyroid stimulating hormone
• Creatine kinase, if pain or muscle weakness present
• Other ???
• The doctor-patient relationship is of profound importance.
The physician will act as a guide in establishing therapeutic goals:
o Accomplishing the activities of daily living
o Returning to work
o Maintaining interpersonal relationships
o Performing some form of daily exercise
• Brief regularly scheduled appointments
• Treat the underlying cause
• Antidepressants :
patients whose illness has features of depression.
response to antidepressant therapy ????
Antidepressants may themselves provoke or exacerbate fatigue.
• Cognitive behavioral therapy
Is effective in patients with CFS and idiopathic chronic fatigue.
• Graded exercise therapy
Is effective in patients with CFS and idiopathic chronic fatigue.
• Provision of general sleep hygiene advice and discouraging over-sleeping
• Provision of patient education brochures and other materials, discussion
of various aspects of chronic fatigue, and referral to support groups
• Iron therapy in non-anemic patients with low serum ferritin may improve
symptoms of fatigue
chronic fatigue syndrome
A case of chronic fatigue syndrome is defined by the presence of:
1. Clinically evaluated, unexplained, persistent or relapsing fatigue that is of new or definite onset; is not the result of
ongoing exertion; is not alleviated by rest; and results in substantial reduction in previous levels of occupational, educational,
social, or personal activities
2. Four or more of the following symptoms that persist or recur during six or more consecutive months of illness and that
do not predate the fatigue:
Self-reported impairment in short term memory or concentration
Tender cervical or axillary nodes
Multijoint pain without redness or swelling
Headaches of a new pattern or severity
Post-exertional malaise lasting ≥24 hour
• Is an extremely common complaint
• Represents a very small subset of those who complain of
chronic fatigue < 5%.
• Disorder of young to middle aged adults ( at 30 years)
• CFS is about twice as common in women
• More in Caucasians
Epstein-Barr virus (EBV), xenotropic murine leukemia related virus (XMRV), and
others (retroviruses, human herpesvirus type 6 (HHV-6), enteroviruses, coxsackie B virus)
• Immune dysfunction
• Endocrine-metabolic dysfunction
Low serum cortisol levels, under secretion of corticotropin-releasing hormone, enhanced
serum levels of insulin-like growth factor.
• Sleep disruption
• Sudden onset of fatigue associated with a typical
infection such as an upper respiratory infection.
• Altered sleep and cognition.
• Excessive physical activity exacerbates the
• Numerous other subjective features of CFS
fluctuate with time but do not appear to progress
• Once the inciting illness (if any) is resolved, the
physical examination typically is normal
Easy fatiguability 100
Difficulty concentrating 90
Sore throat 85
Tender lymph nodes 80
Muscle aches 80
Joint aches 75
• Physical examination
• Laboratory testing
• The diagnosis of CFS is one of exclusion
It is generally made if the patient has a typical history, and no abnormality
can be detected on physical examination or in the screening tests.
Promote sleep hygiene.
Regular physical activity.
Psychotherapy: CBT, GET, family therapy.
To relieve the symptoms: antidepressant, NSAID, antimicrobial, Rituximab,
Fatigue occurs in up to 20% of patients seeking care.
Psychological causes should be at the top of the
differential diagnosis for all patients presenting with
fatigue, as the majority of cases have psychiatric causes.
The history can help in determining a psychiatric
versus organic cause and thus aid in directing the
evaluation of fatigue.