Current Medical Diagnosis And Treatment 2012 PdfBy Fulk M. In and pdf 27.04.2021 at 12:15 4 min read
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- Chronic Fatigue Syndrome: Diagnosis and Treatment
- CURRENT Medical Diagnosis and Treatment 2012
- General Internal Medicine
Chronic Fatigue Syndrome: Diagnosis and Treatment
Patient information: See related handout on chronic fatigue syndrome , written by the authors of this article. Chronic fatigue syndrome is characterized by debilitating fatigue that is not relieved with rest and is associated with physical symptoms.
The Centers for Disease Control and Prevention criteria for chronic fatigue syndrome include severe fatigue lasting longer than six months, as well as presence of at least four of the following physical symptoms: postexertional malaise; unrefreshing sleep; impaired memory or concentration; muscle pain; polyarthralgia; sore throat; tender lymph nodes; or new headaches. It is a clinical diagnosis that can be made only when other disease processes are excluded. The etiology of chronic fatigue syndrome is unclear, is likely complex, and may involve dysfunction of the immune or adrenal systems, an association with certain genetic markers, or a history of childhood trauma.
Persons with chronic fatigue syndrome should be evaluated for concurrent depression, pain, and sleep disturbances. Treatment options include cognitive behavior therapy and graded exercise therapy, both of which have been shown to moderately improve fatigue levels, work and social adjustment, anxiety, and postexertional malaise.
No pharmacologic or alternative medicine therapies have been proven effective. Chronic fatigue syndrome CFS is a widespread problem. It is estimated that more than 2 million Americans have CFS, many of whom have not been diagnosed. Persons with chronic fatigue should have an evaluation, including history, physical examination, and initial laboratory testing i. Persons diagnosed with chronic fatigue syndrome should be evaluated and treated for comorbidities, such as sleep disturbance, depression, and pain.
Any comorbidity identified should be treated. Persons diagnosed with chronic fatigue syndrome should be treated with cognitive behavior therapy, graded exercise therapy, or both. Cognitive behavior therapy and graded exercise therapy have been shown to improve fatigue, work and social adjustment, anxiety, and postexertional malaise.
CFS is a clinical diagnosis that can be made only when other etiologies of fatigue have been excluded. Other symptoms must be present, particularly myalgia, and mood and sleep disturbances. Those with an established medical condition known to produce chronic fatigue. Those with a current diagnosis of schizophrenia, manic-depressive illness, substance abuse, eating disorder, or proven organic brain disease. Information from reference 6.
Severe fatigue for longer than six months, and at least four of the following symptoms:. Headache of new type, pattern, or severity. Multijoint pain without swelling or erythema. Muscle pain. Postexertional malaise for longer than 24 hours. Significant impairment in short-term memory or concentration. Sore throat. Tender lymph nodes. Unrefreshing sleep. Information from reference 7. The general approach to a patient with chronic fatigue should start with a history and physical examination, focusing on identifying the most bothersome symptoms and red flag symptoms Table 3 that may indicate a more serious underlying illness based on the National Institute for Health and Clinical Excellence NICE guidelines.
Information from reference 8. Addison disease. Adrenal insufficiency. Cushing disease. Diabetes mellitus. Chronic hepatitis. Human immunodeficiency virus.
Lyme disease. Multiple sclerosis. Parkinson disease. Bipolar disorder. Eating disorder. Major depressive disorder. Somatoform disorders. Substance abuse. Polymyalgia rheumatica.
Rheumatoid arthritis. Systemic lupus erythematosus. Temporal arteritis. Celiac disease. Heart failure. Heavy metal toxicity. Pharmacologic adverse effect. Sleep apnea. Vitamin deficiency. The CDC recommends initial evaluation with urinalysis; complete blood count; comprehensive metabolic panel; and measurement of phosphorus, thyroid-stimulating hormone, and C-reactive protein.
The etiology of CFS is unclear and is likely complex. It remains controversial whether there is a single etiology for CFS; there may be several poorly understood subsets of the illness, or there may be multiple factors that interact with each other. These complex factors, along with the numerous psychiatric comorbidities of CFS, have led some experts to question whether any organic etiology exists.
Current research on CFS focuses on the immune and adrenal systems, genetics, the biopsychosocial model, and sleep and nutrition. Because many symptoms of viral infections and CFS overlap, some physicians have theorized that CFS has a postinfectious etiology.
One popular theory is that CFS is caused by chronic Epstein-Barr virus infection; however, there is only mixed evidence of any association between specific viruses and CFS. Increasing evidence points to areas of genetic susceptibility in patients with CFS. One study found a difference in the expression of certain genes in patients with CFS after exercise that play a role in metabolism and immune responses.
CFS is often associated with depression, which has led many physicians to believe that CFS is a purely somatic illness. Evidence supporting this conclusion is lacking. Strong evidence suggests that childhood trauma increases the risk of CFS by as much as sixfold.
Some persons may assume that childhood trauma decreases resiliency, but there is evidence to suggest that it may also play an organic role by increasing the risk of adrenal system dysfunction.
There is an association between delayed dim light melatonin onset and CFS, suggesting that delayed circadian rhythm could contribute to CFS. One study has shown that persons with CFS have lower ratios of omega-3 to omega-6 unsaturated fatty acids and lower zinc levels than healthy patients. Family physicians should focus initially on management of symptoms that are often comorbid with CFS, including sleep disturbances, depression, and pain.
Although there is no evidence these modalities are effective, they are unlikely to be harmful and may be helpful.
There is less clear evidence regarding the benefit of drug therapy for CFS in patients without comorbid depression or anxiety disorders. Trained psychotherapists providing CBT emphasize the role of thinking and its impact on how persons feel and act. They can help persons with CFS recognize how their fears of activity lead to behaviors that ultimately cause them to feel more fatigued and disabled.
A large randomized controlled trial in adults with CFS confirmed that CBT has positive effects on fatigue levels, work and social adjustment, depression, anxiety, and postexertional malaise.
Because of this, it is recommended that CBT be individualized to maximize benefit. There are no data to suggest that CBT provided by trained family physicians is better or worse than CBT provided by psychotherapists. Graded exercise therapy involves a gradual increase in physical activity in the hopes of increasing function. A randomized trial found that graded exercise therapy was as effective as CBT for fatigue and the other aspects of functional impairment mentioned previously, except depression.
Most patients chose to walk for exercise. Once this goal was achieved, the patients worked with the supervising physiotherapists monthly to increase the intensity of their aerobic exercise.
Several other studies have found consistent results. One study has shown that an educational intervention known as pragmatic rehabilitation provided by specially trained nurses improves fatigue in persons with CFS; however, the improvement did not persist after 70 weeks. The intervention included education about CFS, followed by a negotiated treatment plan of gradually increased activity. Despite the positive results with CBT and graded exercise therapy, the effects are usually moderate and rarely lead to resolution of CFS.
Patients with poor social adjustment, a strong belief in an organic cause for fatigue, or some sort of sickness benefit i. Other treatments that did not improve CFS symptoms in clinical trials include homeopathic treatments 36 and multivitamins. Several pharmacologic treatments for CFS have had disappointing results in clinical trials, with weak effects of questionable clinical significance or no evidence of benefit at all.
There is no good evidence to support the use of antiviral medications, hydrocortisone, or fludrocortisone; only small or poorly designed studies exist. One study showed some clinical improvement in CFS after treatment with staphylococcus toxoid; the authors theorized that the treatment stimulated the hypoactive immune systems of persons with CFS and subsequently improved their fatigue.
However, the treatment needed to be continued to prevent relapse of symptoms. Staphylococcus toxoid is not widely available and cannot currently be recommended as a treatment for CFS. Other treatments that did not improve CFS symptoms in clinical trials include methylphenidate, 40 melatonin, 19 citalopram Celexa; used in patients without depression , 41 and galantamine Razadyne.
The search included randomized controlled trials and clinical trials in English from the past 10 years. Search date: August 26, Already a member or subscriber? Log in.
CURRENT Medical Diagnosis and Treatment 2012
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Medical diagnosis abbreviated Dx  or D S is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as diagnosis with the medical context being implicit. The information required for diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures , such as medical tests , are also done during the process. Sometimes posthumous diagnosis is considered a kind of medical diagnosis. Diagnosis is often challenging, because many signs and symptoms are nonspecific.
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General Internal Medicine
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Patient information: See related handout on chronic fatigue syndrome , written by the authors of this article. Chronic fatigue syndrome is characterized by debilitating fatigue that is not relieved with rest and is associated with physical symptoms. The Centers for Disease Control and Prevention criteria for chronic fatigue syndrome include severe fatigue lasting longer than six months, as well as presence of at least four of the following physical symptoms: postexertional malaise; unrefreshing sleep; impaired memory or concentration; muscle pain; polyarthralgia; sore throat; tender lymph nodes; or new headaches.
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