a.fardmousavi fatique fatigue refers to a sensation of exhaustion during or after usual activities,...

A.FardmousaviA.Fardmousavi

FatiqueFatique

Fatigue refers to a sensation of Fatigue refers to a sensation of exhaustion during or after usual exhaustion during or after usual activities, or a feeling of inadequate activities, or a feeling of inadequate energy to begin these activities. It energy to begin these activities. It should be distinguished from should be distinguished from somnolence, dyspnea, and somnolence, dyspnea, and weakness, although these symptoms weakness, although these symptoms often are associated with fatigue. often are associated with fatigue.


Fatigue may be divided into Fatigue may be divided into three categories based upon the three categories based upon the

duration of symptoms:duration of symptoms: 1- Recent fatigue refers to symptoms 1- Recent fatigue refers to symptoms

lasting less than one monthlasting less than one month

2- Prolonged fatigue refers to symptoms 2- Prolonged fatigue refers to symptoms lasting for more than one monthlasting for more than one month

3- Chronic fatigue refers to symptoms 3- Chronic fatigue refers to symptoms lasting over six months, but does not lasting over six months, but does not necessarily imply the presence of the necessarily imply the presence of the chronic fatigue syndromechronic fatigue syndrome


Chronic fatigue syndromeChronic fatigue syndrome

The chronic fatigue syndrome is an uncommon The chronic fatigue syndrome is an uncommon cause of chronic fatigue, although it is cause of chronic fatigue, although it is important to make the distinction between important to make the distinction between the two entities. The revised Centers for the two entities. The revised Centers for Disease Control definition of chronic fatigue Disease Control definition of chronic fatigue syndrome states that patients must have syndrome states that patients must have clinically evaluated, unexplained, persistent clinically evaluated, unexplained, persistent or relapsing fatigue plus four or more or relapsing fatigue plus four or more specifically defined associated symptoms. In specifically defined associated symptoms. In contrast, chronic fatigue itself is simply contrast, chronic fatigue itself is simply defined by the presence of fatigue for longer defined by the presence of fatigue for longer than six months. than six months.


Idiopathic chronic fatigueIdiopathic chronic fatigue

Fatigue for which no medical or psychiatric Fatigue for which no medical or psychiatric explanation can be found is seen in 8.5 to explanation can be found is seen in 8.5 to 34 percent of patients with this complaint. If 34 percent of patients with this complaint. If the fatigue persists for over six months and the fatigue persists for over six months and is debilitating but does not meet criteria for is debilitating but does not meet criteria for the chronic fatigue syndrome, it is termed the chronic fatigue syndrome, it is termed idiopathic or nonspecific chronic fatigue. idiopathic or nonspecific chronic fatigue. The disability rates and health care The disability rates and health care utilization in these patients is similar to utilization in these patients is similar to those with chronic fatigue syndrome. those with chronic fatigue syndrome. Idiopathic chronic fatigue may represent Idiopathic chronic fatigue may represent part of the spectrum of a continuum of part of the spectrum of a continuum of illness that includes the chronic fatigue illness that includes the chronic fatigue syndrome. syndrome.


HistoryHistory

Fatigue that is due to an underlying Fatigue that is due to an underlying medical or psychiatric disorder medical or psychiatric disorder usually presents as one of several usually presents as one of several reported symptoms. A specific cause reported symptoms. A specific cause for fatigue is found less frequently for fatigue is found less frequently when fatigue itself is the principal when fatigue itself is the principal concern with few or no other concern with few or no other symptoms. symptoms.


The clinician should rely upon open-The clinician should rely upon open-ended questions, encouraging the ended questions, encouraging the

patient to describe the fatigue in his patient to describe the fatigue in his or her own words. Questions and or her own words. Questions and comments such as "What do you comments such as "What do you

mean by fatigue?" or "Please mean by fatigue?" or "Please describe what you mean" may elicit describe what you mean" may elicit

responses which suggest a responses which suggest a generalized sense of tiredness that generalized sense of tiredness that

help distinguish fatigue from help distinguish fatigue from dyspnea, somnolence, and true dyspnea, somnolence, and true

weakness.weakness.


Patients with organ-based Patients with organ-based medical illness often associate medical illness often associate

their fatigue with activities they their fatigue with activities they are unable to complete. In are unable to complete. In

contrast, patients with fatigue contrast, patients with fatigue that is not organ-based are tired that is not organ-based are tired all the time; their fatigue is not all the time; their fatigue is not necessarily related to exertion, necessarily related to exertion, nor does it improve with rest. nor does it improve with rest.


The impact and duration of The impact and duration of fatigue should be assessed to fatigue should be assessed to

determine whether further determine whether further history and evaluation should history and evaluation should

focus upon the fatigue itself, or focus upon the fatigue itself, or whether the fatigue should whether the fatigue should

simply be noted but not explored simply be noted but not explored directly (at least not at the first directly (at least not at the first

visit). visit).


Fatigue of recent onset may be Fatigue of recent onset may be short-lived, while fatigue that lasts short-lived, while fatigue that lasts

six months may represent a chronic six months may represent a chronic and potentially debilitating illness. and potentially debilitating illness. The clinician should determine the The clinician should determine the

extent to which the patient's fatigue extent to which the patient's fatigue interferes with work, family, or interferes with work, family, or

activities of daily living, and what activities of daily living, and what changes in lifestyle the patient has changes in lifestyle the patient has

made in response to his or her made in response to his or her fatigue. fatigue.


The history should include The history should include questions screening for questions screening for

psychiatric disorders (particularly psychiatric disorders (particularly depression, anxiety disorders, depression, anxiety disorders, somatization disorders, and somatization disorders, and

substance abuse) early in the substance abuse) early in the evaluation of the fatigued evaluation of the fatigued

patient in view of the strong patient in view of the strong relationship between chronic relationship between chronic fatigue and psychiatric illness fatigue and psychiatric illness

described above described above


There is a general perception There is a general perception among practitioners that among practitioners that patients who complain of patients who complain of

chronic fatigue are reluctant chronic fatigue are reluctant to accept a psychologic to accept a psychologic

explanation for their explanation for their symptoms. However, up to symptoms. However, up to two-thirds of patients with two-thirds of patients with fatigue, when asked, will fatigue, when asked, will

acknowledge a psychosocial acknowledge a psychosocial contribution to this symptom contribution to this symptom


The quantity and quality of the The quantity and quality of the patient's sleep should be patient's sleep should be

assessed to determine whether assessed to determine whether or not sleep improves the or not sleep improves the patient's symptoms. Such patient's symptoms. Such

improvement may suggest a improvement may suggest a primary sleep disorder or primary sleep disorder or

disturbed sleep as an etiology for disturbed sleep as an etiology for the patient's fatigue. the patient's fatigue.


A thorough evaluation of A thorough evaluation of medications, both prescribed medications, both prescribed

and over the counter, should be and over the counter, should be undertaken. Recreational drug undertaken. Recreational drug

use, including alcohol, should be use, including alcohol, should be carefully explored in any patient carefully explored in any patient

with fatigue.with fatigue.


Physical examinationPhysical examination

A complete physical examination is A complete physical examination is important to exclude some specific important to exclude some specific causes of fatigue. The physical causes of fatigue. The physical examination also helps to establish the examination also helps to establish the doctor-patient relationship, letting the doctor-patient relationship, letting the patient know that his or her complaint is patient know that his or her complaint is being taken seriously and is worth being taken seriously and is worth investigating. investigating.


The general appearance of The general appearance of the patient should be the patient should be

considered for possible signs considered for possible signs of a psychiatric disorder such of a psychiatric disorder such

as a diminished level of as a diminished level of alertness, psychomotor alertness, psychomotor

agitation or retardation, and agitation or retardation, and poor grooming.poor grooming.


A thorough evaluation for A thorough evaluation for lymphadenopathy, a possible lymphadenopathy, a possible

sign of chronic infection or sign of chronic infection or malignancy, should be malignancy, should be

performed.performed.


Pallor, tachycardia, and a Pallor, tachycardia, and a systolic ejection murmur may systolic ejection murmur may

suggest anemia. suggest anemia.


Evidence of thyroid disease Evidence of thyroid disease should be sought, including a should be sought, including a

goiter or thyroid nodule, goiter or thyroid nodule, ophthalmologic changes, and ophthalmologic changes, and

delayed deep tendon delayed deep tendon reflexes. reflexes.


The cardiopulmonary The cardiopulmonary examination should focus examination should focus upon detecting signs of upon detecting signs of

congestive heart failure and congestive heart failure and chronic lung disease, both chronic lung disease, both

important causes of fatigue.important causes of fatigue.


A complete neurologic A complete neurologic examination is warranted, examination is warranted, including assessment of including assessment of muscle bulk, tone and muscle bulk, tone and

strength, abnormalities which strength, abnormalities which would suggest a would suggest a

neuromuscular disorder to neuromuscular disorder to account for the patient's account for the patient's

fatigue.fatigue.


Laboratory studiesLaboratory studies

Laboratory evaluations in the absence of Laboratory evaluations in the absence of a positive history or physical examination a positive history or physical examination are of little diagnostic utility in the are of little diagnostic utility in the evaluation of the fatigued patient evaluation of the fatigued patient


1-complete blood count with 1-complete blood count with differential differential

2-erythrocyte sedimentation rate 2-erythrocyte sedimentation rate

3-chemistry screen including 3-chemistry screen including liver function tests and liver function tests and

measurement of serum creatine measurement of serum creatine kinase, calcium, and thyroid kinase, calcium, and thyroid stimulating hormone (TSH). stimulating hormone (TSH).

4-HIV testing 4-HIV testing 5-PPD placement 5-PPD placement


In menstruating women, it In menstruating women, it may be appropriate to check may be appropriate to check

iron studies even in the iron studies even in the absence of anemia since absence of anemia since

treatment with iron has been treatment with iron has been found to help some women found to help some women

with a normal hemoglobin but with a normal hemoglobin but low serum ferritin low serum ferritin


Screening examinations Screening examinations appropriate for the age and appropriate for the age and sex of the patient, such as sex of the patient, such as

mammography and mammography and sigmoidoscopy, should be sigmoidoscopy, should be performed at some point performed at some point

during the evaluation.during the evaluation.


weaknessweakness

The evaluation of the patient presenting The evaluation of the patient presenting with a complaint of "weakness" involves with a complaint of "weakness" involves three stepsthree steps

1-Distinguishing true muscle weakness from 1-Distinguishing true muscle weakness from functional motor impairment not due to functional motor impairment not due to loss of muscle powerloss of muscle power

2- Localizing the site of the lesion within 2- Localizing the site of the lesion within the neuromuscular system that is the neuromuscular system that is producing weaknessproducing weakness

3- Determining the cause of the lesion 3- Determining the cause of the lesion


DISTINGUISHING TRUE DISTINGUISHING TRUE MUSCLE WEAKNESS FROM MUSCLE WEAKNESS FROM FUNCTIONAL WEAKNESSFUNCTIONAL WEAKNESS

Many patients who complain of Many patients who complain of weakness are not objectively weak weakness are not objectively weak when muscle strength is formally when muscle strength is formally tested. A careful history and physical tested. A careful history and physical examination will permit the examination will permit the distinction between functional distinction between functional disease and true weakness. disease and true weakness.


HistoryHistory

A variety of systemic disorders can induce the A variety of systemic disorders can induce the functional symptom of weakness. Included in this functional symptom of weakness. Included in this group are cardiopulmonary disease, joint disease, group are cardiopulmonary disease, joint disease, anemia, cachexia from malignancy or chronic anemia, cachexia from malignancy or chronic infectious or inflammatory disease, depression, infectious or inflammatory disease, depression, deconditioning, neuropathies, and demyelinating deconditioning, neuropathies, and demyelinating diseases. Therefore, the possibility of functional diseases. Therefore, the possibility of functional weakness should be considered in a patient weakness should be considered in a patient known to have any of these conditions. known to have any of these conditions. Furthermore, careful questioning will reveal that Furthermore, careful questioning will reveal that the patient is limited by shortness of breath, the patient is limited by shortness of breath, chest pain, joint pain, fatigue, poor exercise chest pain, joint pain, fatigue, poor exercise tolerance, paresthesias, or spasticity rather than tolerance, paresthesias, or spasticity rather than a true decrease in muscle power. a true decrease in muscle power.


Patients with functional disease usually Patients with functional disease usually complain that they are weak. In complain that they are weak. In comparison, those with true muscle comparison, those with true muscle weakness typically complain that they weakness typically complain that they are unable to perform specific tasks, such are unable to perform specific tasks, such as climbing stairs or combing hair, or that as climbing stairs or combing hair, or that they have a feeling of "heaviness" or they have a feeling of "heaviness" or "stiffness" in their limbs. Muscle pain is "stiffness" in their limbs. Muscle pain is uncommon with true weakness, but is uncommon with true weakness, but is often a problem for patients with often a problem for patients with overexertion, cramps, or fibromyalgia overexertion, cramps, or fibromyalgia


Physical examinationPhysical examination

As with the history, the physical As with the history, the physical examination should include a careful examination should include a careful search for one of the disorders that search for one of the disorders that can cause functional weakness as can cause functional weakness as well as testing of muscle strength. In well as testing of muscle strength. In addition, two general observations addition, two general observations may be helpful:may be helpful:


Muscle strength is Muscle strength is preserved in patients with preserved in patients with cachexia despite advanced cachexia despite advanced generalized muscle atrophy. generalized muscle atrophy. In contrast, patients with true In contrast, patients with true

muscle weakness due to a muscle weakness due to a myopathy generally have myopathy generally have normal muscle bulk at the normal muscle bulk at the

time of presentation. time of presentation.


Muscle tenderness is usually Muscle tenderness is usually not associated with one of the not associated with one of the

causes of true muscle weakness. causes of true muscle weakness. There are, however, exceptions There are, however, exceptions

to this general rule including to this general rule including infectious myopathies such as infectious myopathies such as trichinosis and viral myositis, trichinosis and viral myositis,

certain drug-induced certain drug-induced myopathies, thyroid myopathy, myopathies, thyroid myopathy,

and the inherited metabolic and the inherited metabolic myopathies.myopathies.


True muscle weakness is True muscle weakness is documented by formal muscle documented by formal muscle

testing. The strength of each muscle testing. The strength of each muscle can be assessed by determining can be assessed by determining

how much force is required by the how much force is required by the examiner to overcome maximal examiner to overcome maximal

contraction by the patient. A widely contraction by the patient. A widely used system to measure muscle used system to measure muscle

strength is the grading system from strength is the grading system from the Medical Research Council which the Medical Research Council which is based upon a scale of zero to five is based upon a scale of zero to five


Zero — no contractionZero — no contraction

One — flicker or trace of contraction One — flicker or trace of contraction

Two — muscle contraction possible Two — muscle contraction possible only with gravity eliminatedonly with gravity eliminated

Three — muscle contraction against Three — muscle contraction against gravity onlygravity only

Four — power decreased but muscle Four — power decreased but muscle contraction possible against resistancecontraction possible against resistance

Five — normal power resistance Five — normal power resistance

a.fardmousavi fatique fatigue refers to a sensation of exhaustion during or after usual activities,...

Documents

fardmousavi fatigue

presence of fatigue

recent fatigue

prolonged fatigue

relapsing fatigue

nonspecific chronic

chronic fatigue syndrome

fardmousavi fatique