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FATIGUE & CHRONIC FATIGUE SYNDROME
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Weight loss Fever Sleep-disordered breathing Medications Substance use
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As an isolated symptom, fatigue accounts for 1 3% of visits to generalists The symptom of fatigue may be less well defined and explained by patients than symptoms associated with specific functions Fatigue or lassitude and the closely related complaints of weakness, tiredness, and lethargy are often attributed to overexertion, poor physical conditioning, sleep disturbance, obesity, undernutrition, and emotional problems A history of the patient s daily living and working habits may obviate the need for extensive and unproductive diagnostic studies
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A Fatigue
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Clinically relevant fatigue is composed of three major components: generalized weakness (difficulty in initiating activities); easy fatigability (difficulty in completing activities); and mental fatigue (difficulty with concentration and memory)
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A Fatigue
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Management of fatigue involves identification and treatment of conditions that contribute to fatigue, such as cancer, pain, depression, weight loss, and anemia Resistance training and aerobic exercise lessens fatigue and improves performance for a number of chronic conditions
CMDT 2008
1 Clinically evaluate cases of prolonged or chronic fatigue by: A History and physical examination; B Mental status examination (abnormalities require appropriate psychiatric, psychological, or neurologic examination); C Tests (abnormal results that strongly suggest an exclusionary condition must be resolved): 1 Screening laboratory tests: CBC, ESR, ALT, total protein, albumin, globulin, alkaline phosphatase, Ca2+, PO43 , glucose, BUN, electrolytes, creatinine, TSH, and UA 2 Additional tests as clinically indicated to exclude other diagnoses
Reject diagnosis if another cause for chronic fatigue is found
2 Classify case as either chronic fatigue syndrome or idiopathic chronic fatigue if fatigue persists or relapses for 6 months
A Classify as chronic fatigue syndrome if: 1 Criteria for severity of fatigue are met, and 2 Four or more of the following symptoms are concurrently present for 6 months: Impaired memory or concentration Sore throat Tender cervical or axillary lymph nodes Muscle pain Multijoint pain New headaches Unrefreshing sleep Postexertion malaise
B Classify as idiopathic chronic fatigue if fatigue severity or symptom criteria for chronic fatigue syndrome are not met
Figure 2 2 Evaluation and classification of unexplained chronic fatigue (CBC, complete blood count; ESR, erythrocyte sedimentation rate; ALT, alanine aminotransferase; Ca2+, calcium; PO43 , phosphate; BUN, blood urea nitrogen; TSH, thyroidstimulating hormone; UA, urinalysis) (Modified and reproduced, with permission, from Fukuda K et al The chronic fatigue syndrome: a comprehensive approach to its definition and study Ann Intern Med 1994 Dec 15;121(12):953 9) associated with a high prevalence of fatigue, including CHF, COPD, arthritis, and cancer Psychostimulants such as methylphenidate have shown inconsistent results in randomized trials of treatment of cancer-related fatigue logic treatment emphasizing self-help and aiming to change perceptions and behaviors that may perpetuate symptoms and disability, is helpful Although few patients are cured, the treatment effect is substantial Response to cognitive-behavioral therapy is not predictable on the basis of severity or duration of chronic fatigue syndrome, although patients with low interest in psychotherapy rarely benefit Graded exercise has also been shown to improve functional work capacity and physical function At present, intensive individual cognitivebehavioral therapy administered by a skilled therapist and graded exercise are the treatments of choice for patients with chronic fatigue syndrome In addition, the clinician s sympathetic listening and explanatory responses can help overcome the patient s frustrations and debilitation by this still mysterious illness All patients should be encouraged to engage in normal activities to the extent possible and should be reassured that full recovery is eventually possible in most cases
B Chronic Fatigue Syndrome
A variety of agents and modalities have been tried for the treatment of chronic fatigue syndrome Acyclovir, intravenous immunoglobulin, nystatin, and low-dose hydrocortisone/fludrocortisone do not improve symptoms There is a greater prevalence of past and current psychiatric diagnoses in patients with this syndrome Affective disorders are especially common, but fluoxetine alone, 20 mg daily, is not beneficial Patients with chronic fatigue syndrome have benefited from a comprehensive multidisciplinary intervention, including optimal medical management, treating any ongoing affective or anxiety disorder pharmacologically, and implementing a comprehensive cognitive-behavioral treatment program Cognitive-behavioral therapy, a form of nonpharmaco-
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