how to create barcode in using c# FATIGUE, ASTHENIA, ANXIETY, AND DEPRESSIVE REACTIONS in Microsoft Office


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tulated Also, the depression that follows stroke or myocardial infarction frequently presents with the complaint of fatigue rather than other signs of mood disorder Inordinate fatigue is a common complaint among patients with postconcussive syndrome, or what we have termed posttraumatic nervous instability (page 764) Severe fatigue that causes the patient consistently to go to bed right after dinner and makes all mental activity effortful should suggest an associated depression These central fatigue states and their possible mechanisms, almost all speculative, have been discussed by Chaudhuri and Behan Also, many states of disordered autonomic function in which static or orthostatic hypotension are features are commonly associated with a fatigue state Whether there is in addition a central autonomic (hypothalamic) fatigue, aside from the endocrine changes discussed below, is uncertain, but such an entity seems plausible and has been included in models of the chronic fatigue illness Systemic Diseases A wide variety of medications and other therapeutic agents, particularly when rst administered, commonly induce fatigue The main offenders in this respect are antihypertensive drugs, especially beta-adrenergic blocking agents, anticonvulsants, antispasticity drugs, anxiolytics, chemotherapy and radiation therapy, and, paradoxically, many antidepressant and antipsychotic drugs Introduction of these medications in gradually escalating doses may obviate the problem, but, just as often, an alternative medicine must be chosen The administration of betainterferon for the treatment of multiple sclerosis (and alpha-interferon for other diseases) induces fatigue of varying degree Plasma exchange for the treatment of immune neuropathies and myasthenia gravis may be followed by fatigue for a day or so; this state should not be mistaken for a worsening of the underlying disease Surgeons and nurses can testify to fatigue that comes with exposure to anesthetics in inadequately ventilated operating rooms Similarly, fatigue and headache may result from exposure to carbon monoxide or natural gas in homes with furnaces in disrepair or from leaking gas pipes (but this is also a frequent delusion in anxious, depressed, or demented patients) The sleep apnea syndrome is an important and often overlooked cause of fatigue and daytime drowsiness In overweight men who snore loudly and need to nap frequently, testing for sleep apnea is indicated (page 344) Correcting the obstructive apnea that underlies this condition leads to a dramatic reduction in fatigue Acute or chronic infection is an important cause of fatigue Everyone, of course, has at some time or other sensed the abrupt onset of exhaustion, a tired ache in the muscles, or an inexplicable listlessness, only to discover later that he was coming down with the u Chronic infections such as hepatitis, tuberculosis, brucellosis, infectious mononucleosis [Epstein-Barr virus (EBV) infection], subacute bacterial endocarditis, and perhaps the chronic effects of Lyme disease may not be evident immediately but should always be suspected when fatigue is a new symptom and disproportionate to other symptoms such as mood change, nervousness, and anxiety More often, the fatigue begins with an obvious infection (such as in uenza, hepatitis, or infectious mononucleosis) but persists for several weeks after the overt manifestations of infection have subsided; it may then be dif cult to decide whether the fatigue represents the lingering effects of the infection or the infection has been complicated by psychologic symptoms during convalescence This dif cult problem is discussed below Patients with systemic lupus, Sjogren syndrome, or polymyalgia rheumatica may com
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plain of severe fatigue; in the last of these, fatigue may be the initial symptom Metabolic and endocrine diseases of various types may cause inordinate degrees of lassitude and fatigue Sometimes there is, in addition, a true muscular weakness In Addison and Simmonds diseases, fatigue may dominate the clinical picture Aldosterone de ciency is another established cause of chronic fatigue In persons with hypothyroidism with or without frank myxedema, lassitude and fatigue are frequent complaints, as are muscle aches and joint pains Fatigue may also be present in patients with hyperthyroidism, but it is usually less troublesome than nervousness Uncontrolled diabetes mellitus is accompanied by excessive fatigability, as are hyperparathyroidism, hypogonadism, and Cushing disease Reduced cardiac output and diminished pulmonary reserve are important causes of breathlessness and fatigue, which are brought out by mild exertion Anemia, when severe, is another cause, probably predicated on a similar inadequacy of oxygen supply to tissues Mild grades of anemia are usually asymptomatic, and lassitude is far too often ascribed to it An occult malignant tumor eg, pancreatic carcinoma may announce itself by inordinate fatigue In patients with metastatic carcinoma, leukemia, or multiple myeloma, fatigue is a prominent symptom Uremia is accompanied by fatigue; the associated anemia may play a role Any type of nutritional de ciency may, when severe, cause lassitude; in its early stages, this may be the chief complaint Weight loss and a history of alcoholism and dietary inadequacy provide the clues to the nature of the illness For several weeks or months following myocardial infarction, some patients complain of fatigue out of all proportion to effort In many of these patients, there is accompanying anxiety or depression Much more dif cult to understand is the complaint of fatigue that sometimes precedes myocardial infarction Pregnancy causes fatigue, which may be profound in the later months To some extent the underlying causes, including the work of carrying excess weight and an anemia, are obvious; but if weight gain and hypertension are associated, pre-eclampsia should be suspected Postviral and Chronic Fatigue Syndromes A particularly dif cult problem arises in the patient who complains of severe fatigue for many months or even years after a bout of infectious mononucleosis or some other viral illness This has been appropriately called the postviral fatigue syndrome The majority of patients are women between 20 and 40 years of age, but there are undoubtedly young men with the same illness A few such patients were found to have unusually high titers of antibody to EBV, which suggested a causal relationship and gave rise to terms such as the chronic infectious mononucleosis or chronic EBV syndrome (Strauss et al) However, subsequent studies made it clear that a vast majority of patients with complaints of chronic fatigue have neither a clear-cut history of infectious mononucleosis nor serologic evidence of such an infection (Strauss; Holmes et al) In some of these patients the fatigue state has allegedly been associated with obscure immunologic abnormalities simliar to those attributed (spuriously) to silicone breast implants or minor trauma The currently fashionable designation for these and other abstruse states of persistent fatigue is the chronic fatigue syndrome Some perspective is provided by the recognition that a malady of this precise nature, under many different names, has long pervaded postindustrial western society, as described by Shorter in an informative history of the chronic
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