SlideShare a Scribd company logo
APPROACHTO
FATIGUE
Raheef Alatassi
5thYear Medical Student
Family Medicine
WHAT IS FATIGUE ??
Definition
• 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.
Cont.
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
separately.
WHAT ISTHE DIFFERENCE
BETWEEN FATIGUE,
DYSPNEA AND MUSCLE
WEAKNESS ?
What is the difference between Fatigue,
dyspnea and muscle weakness ?
Dyspnea
A subjective experience of breathing discomfort that is comprised of qualitatively
distinct sensations that vary in intensity.
Muscle weakness
A. Primary or true muscle weakness
B. Muscle tiredness (ASTHENIA)
EPIDEMIOLOGY
• 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?
Type Definition
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.
ETIOLOGY
• Psychological ?
• Pharmacologic ?
• Endocrine-metabolic ?
• Hematologic ?
• Infectious ?
• Malignancy
• Cardiopulmonary ?
• Disturbed sleep
ETIOLOGY
EVALUATION
• History
• Physical examination
• Laboratory studies
History
• 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.
History
• ID: Age, Gender, Nationality, occupation.
• CC.:
• HPI:
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
History
• P.M Hx. ??
• P.S Hx.
• Family Hx.
• Social Hx. ??
• Drug Hx. ???
• Allergy Hx.
• Systemic review
Physical examination
• 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
disease
• 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:
hyperthyroidism
• Hypotension, pigmentation in skin creases, scars, and buccal mucosa: Addison's
disease
• Pulmonary stasis, elevated jugular venous pressure, ankle oedema: heart failure
Laboratory studies
• Reasonable initial laboratory studies to obtain
include:
• 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 ???
TREATMENT
• 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
TREATMENT
• 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.
TREATMENT
Other measures
• 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
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
and
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
Sore throat
Tender cervical or axillary nodes
Muscle pain
Multijoint pain without redness or swelling
Headaches of a new pattern or severity
Unrefreshing sleep
Post-exertional malaise lasting ≥24 hour
EPIDEMIOLOGY
• 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
ETIOLOGY
• Idiopathic
• Infection
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.
• Depression
• Sleep disruption
Clinical presentation
• Sudden onset of fatigue associated with a typical
infection such as an upper respiratory infection.
• Altered sleep and cognition.
• Excessive physical activity exacerbates the
symptoms
• 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
Symptom
Percent
of
patients
Easy fatiguability 100
Difficulty concentrating 90
Headache 90
Sore throat 85
Tender lymph nodes 80
Muscle aches 80
Joint aches 75
Feverishness 75
Diagnosis
• History
• 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.
TREATMENT
Promote sleep hygiene.
Non pharmacological:
 Regular physical activity.
 Optimal diet.
 Psychotherapy: CBT, GET, family therapy.
Pharmacological:
To relieve the symptoms: antidepressant, NSAID, antimicrobial, Rituximab,
acyclovir,
KEY POINTS
 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.
References
1- http://www.uptodate.com/contents/approach-to-the-adult-
patient-with-fatigue#H10
2- http://www.uptodate.com/contents/clinical-features-and-
diagnosis-of-chronic-fatigue-syndrome?source=see_link#H15
3- http://www.uptodate.com/contents/treatment-of-chronic-
fatigue-syndrome?source=see_link&anchor=H4#H6
4- http://www.cmaj.ca/content/174/6/765.full
5- http://bestpractice.bmj.com/best-
practice/monograph/571/diagnosis.html
Thank you

More Related Content

What's hot

Lupus nephritis 2016
Lupus nephritis 2016Lupus nephritis 2016
Lupus nephritis 2016
drsamianik
 
History & examination of edema
History & examination of edemaHistory & examination of edema
History & examination of edema
Abino David
 
UG CASE PRESENTATION ON INGUINAL HERNIA
UG CASE PRESENTATION ON INGUINAL HERNIAUG CASE PRESENTATION ON INGUINAL HERNIA
UG CASE PRESENTATION ON INGUINAL HERNIA
Ayesha Huma
 
Acute kidney injury(AKI)
Acute kidney injury(AKI)Acute kidney injury(AKI)
Acute kidney injury(AKI)
Abdusalam Halboup
 
Approach to a patient with stroke
Approach to a patient with stroke Approach to a patient with stroke
Approach to a patient with stroke
Ashwin Haridas
 
Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
Hepatic Encephalopathy -Pathophysiology,Evaluation And ManagementHepatic Encephalopathy -Pathophysiology,Evaluation And Management
Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
Santosh Narayankar
 
Spontaneous Bacterial Peritonitis (SBP)
Spontaneous Bacterial Peritonitis (SBP)Spontaneous Bacterial Peritonitis (SBP)
Spontaneous Bacterial Peritonitis (SBP)
Basant Raj Joshi
 
Hepato&spleenomegaly
Hepato&spleenomegalyHepato&spleenomegaly
Hepato&spleenomegaly
Subash Arun
 
Approach to arthritis
Approach to arthritisApproach to arthritis
Approach to arthritis
Shivshankar Badole
 
Approach to abdominal pain
Approach to abdominal pain Approach to abdominal pain
Approach to abdominal pain
Patinya Yutchawit
 
Chronic liver disease
Chronic liver diseaseChronic liver disease
Chronic liver diseasePuneet Shukla
 
External markers of tuberculosis
External markers of tuberculosisExternal markers of tuberculosis
External markers of tuberculosisKurian Joseph
 
Autoimmune hepatitis rajesh
Autoimmune hepatitis rajeshAutoimmune hepatitis rajesh
Autoimmune hepatitis rajesh
Mohit Aggarwal
 
Approach to a young hypertensive patient: Investigations and diagnosis
Approach to a young hypertensive patient: Investigations and diagnosisApproach to a young hypertensive patient: Investigations and diagnosis
Approach to a young hypertensive patient: Investigations and diagnosismeducationdotnet
 
Approach to history taking in a patient with fever
Approach  to  history  taking  in  a  patient  with  feverApproach  to  history  taking  in  a  patient  with  fever
Approach to history taking in a patient with fever
Reina Ramesh
 
Pancytopenia
PancytopeniaPancytopenia
Pancytopenia
ahmed mjali
 
Chest pain
Chest painChest pain
Chest pain
autumnpianist
 
Approach to splenomegaly
Approach to splenomegalyApproach to splenomegaly
Approach to splenomegaly
Sarath Menon
 
Approach to Anemia
Approach to AnemiaApproach to Anemia
Approach to Anemia
Ahmed Azhad
 
Haematemesis and malena
Haematemesis and malenaHaematemesis and malena
Haematemesis and malena
Mohammed Musa
 

What's hot (20)

Lupus nephritis 2016
Lupus nephritis 2016Lupus nephritis 2016
Lupus nephritis 2016
 
History & examination of edema
History & examination of edemaHistory & examination of edema
History & examination of edema
 
UG CASE PRESENTATION ON INGUINAL HERNIA
UG CASE PRESENTATION ON INGUINAL HERNIAUG CASE PRESENTATION ON INGUINAL HERNIA
UG CASE PRESENTATION ON INGUINAL HERNIA
 
Acute kidney injury(AKI)
Acute kidney injury(AKI)Acute kidney injury(AKI)
Acute kidney injury(AKI)
 
Approach to a patient with stroke
Approach to a patient with stroke Approach to a patient with stroke
Approach to a patient with stroke
 
Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
Hepatic Encephalopathy -Pathophysiology,Evaluation And ManagementHepatic Encephalopathy -Pathophysiology,Evaluation And Management
Hepatic Encephalopathy -Pathophysiology,Evaluation And Management
 
Spontaneous Bacterial Peritonitis (SBP)
Spontaneous Bacterial Peritonitis (SBP)Spontaneous Bacterial Peritonitis (SBP)
Spontaneous Bacterial Peritonitis (SBP)
 
Hepato&spleenomegaly
Hepato&spleenomegalyHepato&spleenomegaly
Hepato&spleenomegaly
 
Approach to arthritis
Approach to arthritisApproach to arthritis
Approach to arthritis
 
Approach to abdominal pain
Approach to abdominal pain Approach to abdominal pain
Approach to abdominal pain
 
Chronic liver disease
Chronic liver diseaseChronic liver disease
Chronic liver disease
 
External markers of tuberculosis
External markers of tuberculosisExternal markers of tuberculosis
External markers of tuberculosis
 
Autoimmune hepatitis rajesh
Autoimmune hepatitis rajeshAutoimmune hepatitis rajesh
Autoimmune hepatitis rajesh
 
Approach to a young hypertensive patient: Investigations and diagnosis
Approach to a young hypertensive patient: Investigations and diagnosisApproach to a young hypertensive patient: Investigations and diagnosis
Approach to a young hypertensive patient: Investigations and diagnosis
 
Approach to history taking in a patient with fever
Approach  to  history  taking  in  a  patient  with  feverApproach  to  history  taking  in  a  patient  with  fever
Approach to history taking in a patient with fever
 
Pancytopenia
PancytopeniaPancytopenia
Pancytopenia
 
Chest pain
Chest painChest pain
Chest pain
 
Approach to splenomegaly
Approach to splenomegalyApproach to splenomegaly
Approach to splenomegaly
 
Approach to Anemia
Approach to AnemiaApproach to Anemia
Approach to Anemia
 
Haematemesis and malena
Haematemesis and malenaHaematemesis and malena
Haematemesis and malena
 

Viewers also liked

12 causes of fatigue
12 causes of fatigue12 causes of fatigue
12 causes of fatigue
RadKast
 
Case presentation 2
Case presentation 2Case presentation 2
Case presentation 2
Arushi Prakash
 
Case Study - Iron Deficiency Anemia
Case Study - Iron Deficiency AnemiaCase Study - Iron Deficiency Anemia
Case Study - Iron Deficiency Anemia
Selena Souriya
 
Approach to tall stature
Approach to tall statureApproach to tall stature
Approach to tall stature
Dr Inayat Ullah
 
CASE OF FEVER WITH LYMPHADENOPATHY, SPLENOMEGALY AND PANCYTOPENIA
CASE OF FEVER WITH LYMPHADENOPATHY,   SPLENOMEGALY AND PANCYTOPENIACASE OF FEVER WITH LYMPHADENOPATHY,   SPLENOMEGALY AND PANCYTOPENIA
CASE OF FEVER WITH LYMPHADENOPATHY, SPLENOMEGALY AND PANCYTOPENIA
Gaurav Jain
 
Precocious puberty ppt
Precocious puberty pptPrecocious puberty ppt
Precocious puberty ppt
Emmanuel Umoh
 
Medicine 5th year, 11th lecture/part two (Dr. Sabir)
Medicine 5th year, 11th lecture/part two (Dr. Sabir)Medicine 5th year, 11th lecture/part two (Dr. Sabir)
Medicine 5th year, 11th lecture/part two (Dr. Sabir)
College of Medicine, Sulaymaniyah
 
gc_molecularmotorscourse_97
gc_molecularmotorscourse_97gc_molecularmotorscourse_97
gc_molecularmotorscourse_97Gregory Carroll
 
Dr. Sabir Hussain---CVS Notes
Dr. Sabir Hussain---CVS NotesDr. Sabir Hussain---CVS Notes
Dr. Sabir Hussain---CVS NotesDrSabirHussain
 
Presentation anemia
Presentation anemiaPresentation anemia
Presentation anemia
cdsf
 
Duodenal vs-gastric
Duodenal vs-gastricDuodenal vs-gastric
Duodenal vs-gastric
QD Nurses
 
Innate immunity: An Over view
Innate immunity: An Over viewInnate immunity: An Over view
Innate immunity: An Over view
Muhammad Getso
 
Approach to Macro and Microcephaly
Approach to Macro and MicrocephalyApproach to Macro and Microcephaly
Approach to Macro and MicrocephalyThe Medical Post
 
Indications and complications of blood transfusion
Indications and complications of blood transfusion Indications and complications of blood transfusion
Indications and complications of blood transfusion abhimanyu_ganguly
 
T-Cell Mediated Immunity
T-Cell Mediated ImmunityT-Cell Mediated Immunity
T-Cell Mediated Immunity
Dr Alok Tripathi
 
ECG In Ischemic Heart Disease - Dr Vivek Baliga Review
ECG In Ischemic Heart Disease - Dr Vivek Baliga ReviewECG In Ischemic Heart Disease - Dr Vivek Baliga Review
ECG In Ischemic Heart Disease - Dr Vivek Baliga Review
Dr Vivek Baliga
 
Blood Transfusion
Blood Transfusion	Blood Transfusion
Blood Transfusion Khalid
 

Viewers also liked (20)

12 causes of fatigue
12 causes of fatigue12 causes of fatigue
12 causes of fatigue
 
Cerebral Palsy
Cerebral PalsyCerebral Palsy
Cerebral Palsy
 
Case presentation 2
Case presentation 2Case presentation 2
Case presentation 2
 
Ccp anemia
Ccp anemiaCcp anemia
Ccp anemia
 
Case Study - Iron Deficiency Anemia
Case Study - Iron Deficiency AnemiaCase Study - Iron Deficiency Anemia
Case Study - Iron Deficiency Anemia
 
Approach to tall stature
Approach to tall statureApproach to tall stature
Approach to tall stature
 
CASE OF FEVER WITH LYMPHADENOPATHY, SPLENOMEGALY AND PANCYTOPENIA
CASE OF FEVER WITH LYMPHADENOPATHY,   SPLENOMEGALY AND PANCYTOPENIACASE OF FEVER WITH LYMPHADENOPATHY,   SPLENOMEGALY AND PANCYTOPENIA
CASE OF FEVER WITH LYMPHADENOPATHY, SPLENOMEGALY AND PANCYTOPENIA
 
Precocious puberty ppt
Precocious puberty pptPrecocious puberty ppt
Precocious puberty ppt
 
Medicine 5th year, 11th lecture/part two (Dr. Sabir)
Medicine 5th year, 11th lecture/part two (Dr. Sabir)Medicine 5th year, 11th lecture/part two (Dr. Sabir)
Medicine 5th year, 11th lecture/part two (Dr. Sabir)
 
gc_molecularmotorscourse_97
gc_molecularmotorscourse_97gc_molecularmotorscourse_97
gc_molecularmotorscourse_97
 
Anaphylactic transfusion reaction
Anaphylactic transfusion reactionAnaphylactic transfusion reaction
Anaphylactic transfusion reaction
 
Dr. Sabir Hussain---CVS Notes
Dr. Sabir Hussain---CVS NotesDr. Sabir Hussain---CVS Notes
Dr. Sabir Hussain---CVS Notes
 
Presentation anemia
Presentation anemiaPresentation anemia
Presentation anemia
 
Duodenal vs-gastric
Duodenal vs-gastricDuodenal vs-gastric
Duodenal vs-gastric
 
Innate immunity: An Over view
Innate immunity: An Over viewInnate immunity: An Over view
Innate immunity: An Over view
 
Approach to Macro and Microcephaly
Approach to Macro and MicrocephalyApproach to Macro and Microcephaly
Approach to Macro and Microcephaly
 
Indications and complications of blood transfusion
Indications and complications of blood transfusion Indications and complications of blood transfusion
Indications and complications of blood transfusion
 
T-Cell Mediated Immunity
T-Cell Mediated ImmunityT-Cell Mediated Immunity
T-Cell Mediated Immunity
 
ECG In Ischemic Heart Disease - Dr Vivek Baliga Review
ECG In Ischemic Heart Disease - Dr Vivek Baliga ReviewECG In Ischemic Heart Disease - Dr Vivek Baliga Review
ECG In Ischemic Heart Disease - Dr Vivek Baliga Review
 
Blood Transfusion
Blood Transfusion	Blood Transfusion
Blood Transfusion
 

Similar to Approach to Fatigue

cfs.pptx
cfs.pptxcfs.pptx
cfs.pptx
rameshnatrayan1
 
Chronic fatigue syndrome
Chronic fatigue syndromeChronic fatigue syndrome
Chronic fatigue syndrome
srishti detha
 
Chronic fatugue syndrome
Chronic fatugue syndromeChronic fatugue syndrome
Chronic fatugue syndrome
Nilesh Kucha
 
Psychological and emotional symptoms in patients suffering from chronc fatigu...
Psychological and emotional symptoms in patients suffering from chronc fatigu...Psychological and emotional symptoms in patients suffering from chronc fatigu...
Psychological and emotional symptoms in patients suffering from chronc fatigu...
Tural Abdullayev
 
Somatoform disorders
Somatoform disorders Somatoform disorders
Somatoform disorders
FemiOpadotun
 
Interface between Psychiatry and Medicine.pptx
Interface between Psychiatry and Medicine.pptxInterface between Psychiatry and Medicine.pptx
Interface between Psychiatry and Medicine.pptx
CalebMucho
 
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptxOVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
ValentinaEmeruwa
 
somatic symptom disorder.ppt
somatic symptom disorder.pptsomatic symptom disorder.ppt
somatic symptom disorder.ppt
DrMOHITBANSAL2
 
Fm
FmFm
Approach to First Time Seizures in Adults.pptx
Approach to First Time Seizures in Adults.pptxApproach to First Time Seizures in Adults.pptx
Approach to First Time Seizures in Adults.pptx
hibaantar
 
Hyperventilation syndrome.
Hyperventilation syndrome.Hyperventilation syndrome.
Hyperventilation syndrome.Hiba Ashibany
 
Medically Unexplained Symptoms final 2 15 AUG 2022.pptx
Medically Unexplained Symptoms final 2 15 AUG 2022.pptxMedically Unexplained Symptoms final 2 15 AUG 2022.pptx
Medically Unexplained Symptoms final 2 15 AUG 2022.pptx
RibhavGupta13
 
Psychiatric Disorders-WPS Office 1.pptx
Psychiatric Disorders-WPS Office 1.pptxPsychiatric Disorders-WPS Office 1.pptx
Psychiatric Disorders-WPS Office 1.pptx
Sudipta Roy
 
History Taking .pdf
History Taking .pdfHistory Taking .pdf
History Taking .pdf
Ömer Aslankan
 
Functional disorders
Functional disordersFunctional disorders
Functional disorders
M.Haseeb Ashraf
 
FATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAI
FATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAIFATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAI
FATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAI
Google
 
Defining and measuring fatigue
Defining and measuring fatigueDefining and measuring fatigue
Defining and measuring fatigueChiaying Li
 
Chronic fatigue syndrome
Chronic  fatigue syndromeChronic  fatigue syndrome
Chronic fatigue syndrome
Heba Essawy, MD
 
Recognition and diagnosis of pseudoneurological syndromes
Recognition and diagnosis of pseudoneurological syndromesRecognition and diagnosis of pseudoneurological syndromes
Recognition and diagnosis of pseudoneurological syndromes
SCGH ED CME
 

Similar to Approach to Fatigue (20)

cfs.pptx
cfs.pptxcfs.pptx
cfs.pptx
 
Chronic fatigue syndrome
Chronic fatigue syndromeChronic fatigue syndrome
Chronic fatigue syndrome
 
Chronic fatugue syndrome
Chronic fatugue syndromeChronic fatugue syndrome
Chronic fatugue syndrome
 
Psychological and emotional symptoms in patients suffering from chronc fatigu...
Psychological and emotional symptoms in patients suffering from chronc fatigu...Psychological and emotional symptoms in patients suffering from chronc fatigu...
Psychological and emotional symptoms in patients suffering from chronc fatigu...
 
Somatoform disorders
Somatoform disorders Somatoform disorders
Somatoform disorders
 
Interface between Psychiatry and Medicine.pptx
Interface between Psychiatry and Medicine.pptxInterface between Psychiatry and Medicine.pptx
Interface between Psychiatry and Medicine.pptx
 
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptxOVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
 
somatic symptom disorder.ppt
somatic symptom disorder.pptsomatic symptom disorder.ppt
somatic symptom disorder.ppt
 
Fm
FmFm
Fm
 
Approach to First Time Seizures in Adults.pptx
Approach to First Time Seizures in Adults.pptxApproach to First Time Seizures in Adults.pptx
Approach to First Time Seizures in Adults.pptx
 
Hyperventilation syndrome.
Hyperventilation syndrome.Hyperventilation syndrome.
Hyperventilation syndrome.
 
Medically Unexplained Symptoms final 2 15 AUG 2022.pptx
Medically Unexplained Symptoms final 2 15 AUG 2022.pptxMedically Unexplained Symptoms final 2 15 AUG 2022.pptx
Medically Unexplained Symptoms final 2 15 AUG 2022.pptx
 
Psychiatric Disorders-WPS Office 1.pptx
Psychiatric Disorders-WPS Office 1.pptxPsychiatric Disorders-WPS Office 1.pptx
Psychiatric Disorders-WPS Office 1.pptx
 
History Taking .pdf
History Taking .pdfHistory Taking .pdf
History Taking .pdf
 
Functional disorders
Functional disordersFunctional disorders
Functional disorders
 
FATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAI
FATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAIFATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAI
FATIGUE ASSESMENT & MANGEMENT BY- DR. ANJALI RAI
 
Defining and measuring fatigue
Defining and measuring fatigueDefining and measuring fatigue
Defining and measuring fatigue
 
Chronic fatigue syndrome
Chronic  fatigue syndromeChronic  fatigue syndrome
Chronic fatigue syndrome
 
Recognition and diagnosis of pseudoneurological syndromes
Recognition and diagnosis of pseudoneurological syndromesRecognition and diagnosis of pseudoneurological syndromes
Recognition and diagnosis of pseudoneurological syndromes
 
Weakness
WeaknessWeakness
Weakness
 

More from raheef

Essential Hypertension
Essential Hypertension Essential Hypertension
Essential Hypertension
raheef
 
Obesity in Pediatrics
Obesity in Pediatrics Obesity in Pediatrics
Obesity in Pediatrics
raheef
 
Abnormal Uterine Bleeding AUB
Abnormal Uterine Bleeding AUB Abnormal Uterine Bleeding AUB
Abnormal Uterine Bleeding AUB
raheef
 
Urinary Incontinence
Urinary  Incontinence Urinary  Incontinence
Urinary Incontinence
raheef
 
Case presentation in Dermatology erythrodermic psoriasis
Case presentation in Dermatology erythrodermic psoriasisCase presentation in Dermatology erythrodermic psoriasis
Case presentation in Dermatology erythrodermic psoriasis
raheef
 
Deep neck spaces and infection ENT
Deep neck spaces and infection ENT Deep neck spaces and infection ENT
Deep neck spaces and infection ENT
raheef
 
COPD lecture
COPD  lecture COPD  lecture
COPD lecture raheef
 

More from raheef (7)

Essential Hypertension
Essential Hypertension Essential Hypertension
Essential Hypertension
 
Obesity in Pediatrics
Obesity in Pediatrics Obesity in Pediatrics
Obesity in Pediatrics
 
Abnormal Uterine Bleeding AUB
Abnormal Uterine Bleeding AUB Abnormal Uterine Bleeding AUB
Abnormal Uterine Bleeding AUB
 
Urinary Incontinence
Urinary  Incontinence Urinary  Incontinence
Urinary Incontinence
 
Case presentation in Dermatology erythrodermic psoriasis
Case presentation in Dermatology erythrodermic psoriasisCase presentation in Dermatology erythrodermic psoriasis
Case presentation in Dermatology erythrodermic psoriasis
 
Deep neck spaces and infection ENT
Deep neck spaces and infection ENT Deep neck spaces and infection ENT
Deep neck spaces and infection ENT
 
COPD lecture
COPD  lecture COPD  lecture
COPD lecture
 

Recently uploaded

Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptxMaxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Dr. Rabia Inam Gandapore
 
basicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdfbasicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdf
aljamhori teaching hospital
 
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness JourneyTom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
greendigital
 
NVBDCP.pptx Nation vector borne disease control program
NVBDCP.pptx Nation vector borne disease control programNVBDCP.pptx Nation vector borne disease control program
NVBDCP.pptx Nation vector borne disease control program
Sapna Thakur
 
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
kevinkariuki227
 
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
VarunMahajani
 
Physiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of TastePhysiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of Taste
MedicoseAcademics
 
micro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdfmicro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdf
Anurag Sharma
 
KDIGO 2024 guidelines for diabetologists
KDIGO 2024 guidelines for diabetologistsKDIGO 2024 guidelines for diabetologists
KDIGO 2024 guidelines for diabetologists
د.محمود نجيب
 
Flu Vaccine Alert in Bangalore Karnataka
Flu Vaccine Alert in Bangalore KarnatakaFlu Vaccine Alert in Bangalore Karnataka
Flu Vaccine Alert in Bangalore Karnataka
addon Scans
 
The Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of IIThe Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of II
MedicoseAcademics
 
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidadeNovas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Prof. Marcus Renato de Carvalho
 
heat stroke and heat exhaustion in children
heat stroke and heat exhaustion in childrenheat stroke and heat exhaustion in children
heat stroke and heat exhaustion in children
SumeraAhmad5
 
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.GawadHemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
NephroTube - Dr.Gawad
 
Ophthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE examOphthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE exam
KafrELShiekh University
 
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptxANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
Swetaba Besh
 
Are There Any Natural Remedies To Treat Syphilis.pdf
Are There Any Natural Remedies To Treat Syphilis.pdfAre There Any Natural Remedies To Treat Syphilis.pdf
Are There Any Natural Remedies To Treat Syphilis.pdf
Little Cross Family Clinic
 
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptxPharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Dr. Rabia Inam Gandapore
 
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists  Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Saeid Safari
 
Knee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdfKnee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdf
vimalpl1234
 

Recently uploaded (20)

Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptxMaxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
 
basicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdfbasicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdf
 
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness JourneyTom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
 
NVBDCP.pptx Nation vector borne disease control program
NVBDCP.pptx Nation vector borne disease control programNVBDCP.pptx Nation vector borne disease control program
NVBDCP.pptx Nation vector borne disease control program
 
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
 
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
 
Physiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of TastePhysiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of Taste
 
micro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdfmicro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdf
 
KDIGO 2024 guidelines for diabetologists
KDIGO 2024 guidelines for diabetologistsKDIGO 2024 guidelines for diabetologists
KDIGO 2024 guidelines for diabetologists
 
Flu Vaccine Alert in Bangalore Karnataka
Flu Vaccine Alert in Bangalore KarnatakaFlu Vaccine Alert in Bangalore Karnataka
Flu Vaccine Alert in Bangalore Karnataka
 
The Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of IIThe Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of II
 
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidadeNovas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
 
heat stroke and heat exhaustion in children
heat stroke and heat exhaustion in childrenheat stroke and heat exhaustion in children
heat stroke and heat exhaustion in children
 
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.GawadHemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
 
Ophthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE examOphthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE exam
 
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptxANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
 
Are There Any Natural Remedies To Treat Syphilis.pdf
Are There Any Natural Remedies To Treat Syphilis.pdfAre There Any Natural Remedies To Treat Syphilis.pdf
Are There Any Natural Remedies To Treat Syphilis.pdf
 
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptxPharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
 
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists  Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
 
Knee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdfKnee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdf
 

Approach to Fatigue

  • 3. Definition • 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.
  • 4. Cont. 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 separately.
  • 5. WHAT ISTHE DIFFERENCE BETWEEN FATIGUE, DYSPNEA AND MUSCLE WEAKNESS ?
  • 6. What is the difference between Fatigue, dyspnea and muscle weakness ? Dyspnea A subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. Muscle weakness A. Primary or true muscle weakness B. Muscle tiredness (ASTHENIA)
  • 7. EPIDEMIOLOGY • 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).
  • 8. What is the difference between the CFS, chronic fatigue & idiopathic chronic fatigue? Type Definition 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.
  • 9. ETIOLOGY • Psychological ? • Pharmacologic ? • Endocrine-metabolic ? • Hematologic ? • Infectious ? • Malignancy • Cardiopulmonary ? • Disturbed sleep
  • 11. EVALUATION • History • Physical examination • Laboratory studies
  • 12. History • 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.
  • 13. History • ID: Age, Gender, Nationality, occupation. • CC.: • HPI: 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
  • 14. History • P.M Hx. ?? • P.S Hx. • Family Hx. • Social Hx. ?? • Drug Hx. ??? • Allergy Hx. • Systemic review
  • 15. Physical examination • 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 disease • Neurologic examination: muscle bulk, tone, and strength; deep tendon reflexes; sensory and cranial nerve evaluation
  • 16. 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: hyperthyroidism • Hypotension, pigmentation in skin creases, scars, and buccal mucosa: Addison's disease • Pulmonary stasis, elevated jugular venous pressure, ankle oedema: heart failure
  • 17. Laboratory studies • Reasonable initial laboratory studies to obtain include: • 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 ???
  • 18. TREATMENT • 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
  • 19. TREATMENT • 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.
  • 20. TREATMENT Other measures • 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
  • 22. 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 and 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 Sore throat Tender cervical or axillary nodes Muscle pain Multijoint pain without redness or swelling Headaches of a new pattern or severity Unrefreshing sleep Post-exertional malaise lasting ≥24 hour
  • 23. EPIDEMIOLOGY • 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
  • 24. ETIOLOGY • Idiopathic • Infection 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. • Depression • Sleep disruption
  • 25. Clinical presentation • Sudden onset of fatigue associated with a typical infection such as an upper respiratory infection. • Altered sleep and cognition. • Excessive physical activity exacerbates the symptoms • 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 Symptom Percent of patients Easy fatiguability 100 Difficulty concentrating 90 Headache 90 Sore throat 85 Tender lymph nodes 80 Muscle aches 80 Joint aches 75 Feverishness 75
  • 26. Diagnosis • History • 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.
  • 27. TREATMENT Promote sleep hygiene. Non pharmacological:  Regular physical activity.  Optimal diet.  Psychotherapy: CBT, GET, family therapy. Pharmacological: To relieve the symptoms: antidepressant, NSAID, antimicrobial, Rituximab, acyclovir,
  • 28. KEY POINTS  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.
  • 29. References 1- http://www.uptodate.com/contents/approach-to-the-adult- patient-with-fatigue#H10 2- http://www.uptodate.com/contents/clinical-features-and- diagnosis-of-chronic-fatigue-syndrome?source=see_link#H15 3- http://www.uptodate.com/contents/treatment-of-chronic- fatigue-syndrome?source=see_link&anchor=H4#H6 4- http://www.cmaj.ca/content/174/6/765.full 5- http://bestpractice.bmj.com/best- practice/monograph/571/diagnosis.html

Editor's Notes

  1.  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.
  2. There is debate, however, whether depression in individual patients is the cause or consequence of symptoms of chronic fatigue. 
  3. 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.
  4. 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).
  5. 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
  6. 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).
  7. 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.
  8. 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)
  9. but cases in children have been recognized.