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Chapter 7. Fatigue

Richard J. Simons, MD; Nicole A. Swallow, MD

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• Case Scenario
• Introduction
• Getting Started with the History
• Interview Framework
• Identifying Alarm Symptoms
• Focused Questions
• Diagnostic Approach (Including Algorithm)
• Case Scenario | Resolution
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A 45-year-old woman presents to your clinic after suffering from “months” of feeling bad. She feels tired all the time and is finding it difficult to keep up daily activities. Her tiredness is interfering with her ability to play an active role in the lives of her husband and 2 children. She has no significant past medical history and has not seen a physician in several years.

• What additional information about her “tiredness” do you need?
• How would you classify her fatigue?
• What alarm symptoms would you look for in this patient?
• Would laboratory testing help you to make a diagnosis?

Fatigue is one of the most common symptoms encountered in primary care settings. Twenty-four percent to 32% of adult patients report significant fatigue during visits to their primary care physicians. 1 , 2 Fatigue is a sensation that everyone experiences from time to time; however, it is the persistence of fatigue that is considered abnormal. Common descriptors from patients with fatigue include a lack of energy to complete tasks, exhaustion, and tiredness. Fatigue often signifies underlying medical or psychiatric disease.

The chronic fatigue syndrome (CFS) represents a very small subset of patients with chronic fatigue. CFS remains a controversial subject but probably has existed for centuries under various labels, including effort syndrome (soldier's heart described in 1870), neurasthenia (1890), and more recently, the Gulf War syndrome (1991). Recently, the Centers for Disease Control and Prevention (CDC) developed a tool to assist in the more definitive diagnosis of CFS, expanding upon previous work in this field. 3 Unfortunately, because fatigue may accompany almost any medical or psychological illness, evaluating and treating a patient with fatigue can be particularly challenging and sometimes frustrating for the clinician. A careful history with special attention to psychosocial issues, the physical examination, and a few selected laboratory tests should reveal the cause in most patients.

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Case Study: The Tired Swimmer

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• Page ID 20316

• Shannan Muskopf
• Granite City School District via Biology Corner

Part I: Meet Annie

Annie felt despondent. Her teammates were being kind to her, but she knew that she was the reason that her team lost the swim meet against the neighboring college. How many people could lose with a four-second lead against someone they had beaten so easily last year? As she walked out of the locker room she noticed that the blurred vision and eye strain had returned, even though she was wearing glasses instead of her usual contacts. Her eye strain had become worse over the past month. Over the last week she had had mid-term exams and papers to write and recently typing made her hands and fingers ache and they felt weak. Even swim practice, which helped relieve her stress in the past, had become taxing. Her coach noticed that her times were getting worse, even though he could see that she was working hard in practice.

As Annie walked out of the locker room she looked up and she saw her boyfriend, Matt, waiting for her. As they walked back to her dorm, Annie thought how nice it was to have Matt to support her during such a tough time. Annie was gasping for air and felt weaker than ever after they had walked up the two flights of stairs to her floor. She told herself that she must set some time aside next week to do something about this constant fatigue.

Annie had already packed her bags for the trip home and Matt was able to carry all of her stuff to his car in one trip. When he returned to the room he found Annie reclining on the bed with her eyes closed. He asked her if she was ready to go. “Sure, just can’t keep my eyes open these days. I am sure I’ll be better when we’re home.”

Matt knew that Annie liked to drive, so when they got to the car he handed her the keys. She tried to take them, but her fingers didn’t seem to work and she dropped his keys on the ground. Matt grabbed the keys and opened the passenger door for Annie. As they set off for home, Matt asked, “Are you feeling okay? You’re not usually so exhausted after a swim meet, and you seem to be having trouble catching your breath. I am worried about you.” Matt thought that this was probably the best time to suggest that she see a doctor.

• Summarize the setting (background) for this case.
• What symptoms does Annie exhibit? Prioritize these symptoms in order of what you think is the most concerning and the least concerning.
• What is the one common feature of all of her symptoms?
• When did Matt notice that Annie was having trouble breathing?
• List any diseases, disorders, or health problems that you can think of that might cause these symptoms.

Part II:The Doctor’s Office

On Monday afternoon, Matt drove Annie to her family doctor. She seemed to have slept for most of the weekend, and Matt thought that she looked much better than last Friday after the meet. In fact, she told him that she felt so much better that she really didn’t need to go to the doctor.

“Seriously, this is stupid. I’ve been feeling much better in the past few days. It’s amazing what some rest can do. That’s all I need; I really don’t need a doctor as long as I take a nap periodically. Let’s not waste his time; let’s just go home.” Matt looked at her with his eyebrows raised, “Let’s just hear what he has to say; better safe than sorry.”

Matt sat in the waiting room and Annie went with the nurse. After a few minutes Dr. Jones entered the cubicle, “Well, Annie, what seems to be the problem?”

“It’s nothing, really. I have just been tired lately. You know I’m going to college on a swimming scholarship, but my times have been getting worse this season, and I’ve been short of breath more than usual after my workouts. I think it’s just because I was stressed out over school; I have been feeling much better since I came home last Friday. “I see,” said the doctor. “Have you had any other problems?”

“Well, yes. My hands and fingers seem to get tired when I type, and a few days ago, after a swim meet, my fingers felt too weak to grab my boyfriend’s car keys when he offered them to me; but I was tired after a really hectic week.”

Dr. Jones looked pensive and asked, “Have you had any trouble with your eyes? Like have they been drooping?”

Annie looked confused. “I have had a lot of eye strain and double vision recently. It gets blurry when I stare at the computer screen too long; I seem to get a zillion papers every week. I also think the chlorine level in the pool is too high. Everyone on the team complains about it because, if your goggles come off , your eyes sting like mad.

The doctor smiled, “I swam before those goggles were even invented, so I know what you mean about stinging eyes. But, I think what you’re telling me goes beyond simple fatigue. I’m going to refer you to a neurologist at the hospital.”

5. What specific question does the doctor ask Annie?

6. What excuse does Annie give about her eye strain?

7. What is a neurologist?

8. Based on how the doctor responded, do you think he believes that Annie’s problems are caused by not getting enough sleep?

Part III—The Neurologist

Annie returned to the neurologist’s office with her mother. That morning Annie had been subjected to several different tests and she had been asked to return after lunch when the results would be in. The nurse told her that they were rushing this through because they knew that Annie was only home for a week. Annie and her mother sat in the waiting room for what seemed to be hours. At last the nurse came for them.

“Some of the results are here, and the rest are on their way,” she explained. “So the doctor will see you now.” Annie and her mother went into the doctor’s office and sat down.

“Well, Annie, I have read your family doctor’s notes, and we put you through a battery of tests this morning.” the neurologist skimmed through the chart, “Hmm, blurred vision, weak fingers, and decline in swimming performance. OK, let’s see what we found out today. First, the nerve conduction and the electromyography (emg) tests; these are the only results we have right now. This was the test when they put sticky electrodes on your skin, remember?” Annie nodded.

“Well, for the nerve conduction tests one set of electrodes stimulated the nerve and another recorded its response a little way down the nerve. The nerve conduction results are normal. There is no nerve fatigue and the conduction velocity is fine; nothing wrong with your nerves.”

Annie and her mother looked at each other and smiled with relief.

“Now, the electromyography test involves recording from a muscle; it was done in two stages. The first stage stimulated the muscle directly, and there isn’t too much out of the ordinary there. The second stage is when the nerves were stimulated and the muscle response was recorded. These results concern me because the muscle response decreased quickly during repeated nerve stimulation, indicating that your muscle response fatigued over time.”

8. Summarize the results of the nerve conduction test?

9. What is the EMG test? What did this test reveal about Annie’s muscles?

10. Based on these two tests, does Annie have a nerve problem or a muscle problem?

Part IV—The Neurologist Makes a Diagnosis

They heard a knock at the door and turned to see the nurse enter; she was holding a folder with the hospital’s stamp. The doctor looked over the lab results and then continued.

“I’m afraid I don’t have very good news. Do you remember when the nurse injected that solution into your arm and you said that suddenly you felt much stronger?” Annie nodded.

“That was the edrophonium test. It temporarily relieves symptoms of people who suffer from myasthenia gravis. I am afraid that the diagnosis is confirmed by these lab results, which show the disease.

The nurse handed Annie and her mother a pamphlet about myasthenia gravis while the doctor explained. “Myasthenia gravis causes your immune system to attack the acetylcholine receptors on your muscles. As these receptors stop working, the muscles fatigues easily. Often the first symptom is weakness of the eye muscle.” The doctor held a chart up showing the neuromuscular junction.

11. Label the image below that shows the neuromuscular junction: Sarcomere | Sarcolemma | Synapse | Motor End Plate | Nerve | Vesicles | T- Tubules

12. Add to the drawing by placing stars where the acetylcholine receptors would be located.

13. Edrophonium is a drug the blocks cholinesterase from breaking down acetylcholine in the muscles. Why does this improve Annie’s muscle function?

14. Why is myasthenia gravis called an autoimmune disease?

Modified from: A Case Study on the Nervous System

August 15, 2017

Why Does Being in the Heat Make Us Feel Tired?

A hot summer day makes the body work overtime

By Laura Geggel & LiveScience

Lost Horizon Images Getty Images

If you're out and about on a sweltering day, it probably won't be long before you start to feel tired and sluggish. But why does being out in the heat bring on feelings of drowsiness?

The reason for this lethargy is simple: Your body is working hard to keep you cool, and this extra labor makes you feel tired, said Dr. Michele Casey, the regional medical director at Duke Health in North Carolina.

"Your body, especially in the sun, has to work hard to maintain a consistent, normal, internal temperature," Casey told Live Science. [ What Would Happen If You Fell Into a Volcano? ]

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If you're enjoying this article, consider supporting our award-winning journalism by subscribing . By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.

On a hot day, your body makes several adjustments to maintain its temperature. For instance, it dilates your blood vessels, a process known as vasodilation, which allows more blood to flow near the skin's surface. This allows warm blood to cool off, releasing heat as it travels near the skin, Casey said.

This increased blood flow near the skin explains why some people look redder when they're feeling hot,  according to the BBC .

In addition to vasodilation, the body secretes sweat onto the skin. This sweat then cools the skin as it evaporates, Casey said. But in order to do this extra work, your heart rate increases, as does your  metabolic rate  (the number of calories your body needs to function), she said.

"All that work—increasing your heart rate, your metabolic rate—eventually makes you feel tired or sleepy," Casey said.

Furthermore, most people spend their lives slightly dehydrated. Being hot and sweaty only worsens that dehydration, and a symptom of dehydration is fatigue, she noted.

Getting skin damage from the sun can also heighten dehydration. When the sun's rays beam down on your skin, it can cause pigmentation changes, wrinkles and burns. "These chemical changes actually cause fatigue," Casey said. "That's because your body is working to  repair the damage ."

Sunburns impair your body's ability to regulate its temperature, she said. What's more, when you sunburn, your body diverts fluid from the rest of the body toward the burn in an attempt to heal the skin. This diversion means you have less fluid overall for sweating, which can lead to more dehydration and fatigue, Casey said.

Often, people who are feeling hot might try to cool down with a cool drink, such as alcohol. But alcohol is a diuretic, meaning it may only increase dehydration, Casey said. Coffee, on the other hand, is actually  not a diuretic , according to recent studies. But the best way to fight dehydration is with water and a salty snack, such as pretzels or baked potato chips, Casey said. 

She advised people to be aware of the symptoms of  heat exhaustion : sweating heavily, having a rapid pulse and feeling faint or sleepy. "If that happens, we recommend you get somewhere cool, drink water and see a physician if the symptoms don't improve within about an hour," Casey said.

Heat stroke  is a more serious condition, in which the body's core is 104 degrees Fahrenheit (57.7 degrees Celsius) or hotter. This condition requires emergency treatment, as it can lead to damage to the brain, heart, kidneys and muscle. Symptoms include high body temperature, nausea, vomiting, headache and changes in behavior, such as confusion, agitation or irritability. Other symptoms are slurred speech, seizures or coma.

To cool down, Casey advised going to a cooler environment, such as the shade or an air-conditioned area, especially during the hottest hours between 10 a.m. and 2 p.m. local time. It's also important to  stay hydrated , she said.

Editor's Recommendations

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Copyright 2017  LIVESCIENCE.com , a Purch company. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.   Read the original article  here .

• Medical Library

1 Lethargy summary

Lethargy can be simply defined as a symptom that makes someone feel sluggish and fatigued or sometimes lacking energy. Lethargy can be an indication of a lot of conditions, normally caused by lack of sleep or over-exertion. Lethargy is associated with difficulty in concentration and distraction in performance of normal activity. So, what does lethargic mean?

Usually it is accompanied by apathy or depression and a lack of motivation. In most cases it is caused by lack of adequate sleep. Moreover, it is also caused by lack of exercise, or too much exercise, and improper nutrition.

It can usually be simply resolved by proper nutrition, reduced stress levels, and proper sleeping patterns. However, if you can barely resolve your lethargy issues, it may be a sign of a psychological disorder.

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2 what are the symptoms of lethargy.

If you are feeling the below symptoms, you might consider yourself to feel lethargic.

• Insomnia , fatigue , and weakness
• Abrupt changes in weight, whether loss or gain
• Appetite changes as well as changes in bowel and urine,
• Anxiety and/or depression
• Low concentration and being mentally fatigued throughout the day, no matter the time
• Skin irritation and sometimes rashes
• Dehydration

3 What causes lethargy?

A number of conditions can be considered causes of feeling lethargic.

Here are just a few causes of lethargy:

• Heart disease
• Sleeping and eating disorders
• Thyroid issues
• Side effect from medication, or interaction between various medicines
• Alcohol or drug use
• Anxiety also causes lethargy. Anxiety results in the body releasing adrenaline. Without adrenaline your body lacks stimulation.

4 When do I seek medical help for lethargy?

You should seek medical attention if your lethargy is accompanied by:

• Chest pains
• Back, abdominal or pelvic pain
• Change in heartbeat, especially if the heart beats faster
• Feeling lightheaded

You should seek urgent medication if you are lethargic and bleeding or vomiting blood.

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Why are my eyes sensitive to light, 5 how is lethargy incorporated into diagnosis.

The doctor will be concerned about:

• Your sleeping patterns, how often you feel lethargic and at what time of day.
• She or he will want to know your daily routine, or if you are under stress.
• The doctor will also need to know what you eat, and if you exercise or not.
• If you are under any medication or if you use drugs
• Other symptoms that you are experiencing

If caused by depression, it will last all day beginning in the morning. Lethargy caused by malfunction of the thyroid gland will occur throughout the day, and is accompanied by weight gain, constipation , being more sensitive to cold, and dry skin .

Shortness of breath could be an indication of lung as well as heart problems. In case the cause of lethargy is heart issues, diagnosis will be unclear and normally not relieved by rest or a proper diet. Problems with the cardiovascular or respiratory system, like asthma , could also cause lethargy.

The best way to be sure, of course, is to be examined by a qualified physician. It is usually tested through urine or blood tests, and also imaging.

Lethargy is not necessarily a serious issue, but you might consider visiting your doctor in case of:

• Sudden chest pain
• Energy loss
• Rapid heart rate
• Rapid weight gain
• Shortness of breath

However, if left untreated, it may result in permanent health damage.

Lethargy leads to a decrease in muscular strength, which affects your ability to perform physical activities. If treatment is delayed, it may lead to a permanent lack of response to a stimulus, may it be emotional or physical.

6 How is lethargy treated?

Lethargy is treated depending on its cause. For example, if it is caused by depression, you will be advised to visit a psychologist or psychiatrist for treatment.

If your lethargy is not connected to a root cause, try to get an appropriate amount of sleep and exercise every day. Also make sure you maintain a proper diet for your height and weight.

7 Symptoms of lethargy in depression

Depression is linked to chemical imbalances, therefore making lethargy not only a physical but also a mental condition. Depressed people are more likely to be lethargic. Basically, depression is the lack of motivation to do anything, and the affected individuals tend to be dormant and are often tired.

Lethargy may be considered severe when an individual lacks the drive to even get out of bed.

Symptom of decreased alertness

Decreased alertness is noticeable especially in the morning. It is not uncommon to suffer a decline in your energy levels that makes it difficult to perform even the lightest of tasks. With lethargy, your responses and reflexes are slowed, so loud noises or abrupt disturbances may go unnoticed.

Symptoms of cognitive impairment

Decreased concentration, attention and an exhausted mind makes it difficult to learn. Your memory is altered, making it difficult to remember; moreover, it becomes harder to recognize or solve issues. Over time, you become a slow thinker with reduced mental patience.

Symptoms of sleep disturbance

Insomnia is the most common sign of depression. Depression is characterized by a lot of emotions or lack thereof including: guilt, hopelessness, and a sense of no belonging. These can make it extremely hard to sleep. Due to lack of sleep, lethargy comes as a result. You then have trouble falling asleep, staying asleep, and getting up.

Emotional symptoms

Lethargy leads to a decrease in motivation, and venturing into any sort of activity seems impossible. You develop a constant feeling of boredom and development of anti-social behavior. Activities you once enjoyed become difficult to engage in. Your esteem and self-worth decrease as you begin to feel inadequate.

8 How to prevent lethargy

There are various approaches in preventing lethargy. These can include dietary, lifestyle, sleeping. or psychological approaches. Lethargy is caused by lack of energy and prevention should be aimed at restoring it.

• Drink a lot of water. Lethargy occurs as a result of fatigue that may be an indication of dehydration .
• Monitor your alcohol and caffeine intake.
• Do not skip breakfast or any meals. Skipping meals may result in low levels of blood sugar and a decrease in your energy levels.
• Maintain a healthy diet and avoid over eating.
• Avoid smoking. Research shows that smokers’ energy levels are lower than those of non-smokers
• Be active. Being inactive easily leads to lethargy. Exercise not only refreshes your mind but enables you to sleep better.
• Talk to your managers or HR department at work. If work becomes strenuous or you are having a hard time completing tasks, consider having a meeting rather than stressing about it on your own.
• Avoid sleeping during the day.
• Develop a regular sleeping pattern by going to bed the same time each night.
• Avoid stressful events or activities like over-exercising.
• Refrain from sleeping pills and find a natural way to relax your mind.

Psychological problems

• Confide in someone. Talking therapy is a known solution to help eliminate fatigue and lethargy.
• Avoid stress. A lot of energy is used up when you are stressed. Find some hobbies or activities that relax you.
• Take some time off work. Create recreational time to spend with friends and family. It goes a long way when it comes to relaxing yourself.
• Always think about the results of what you do rather than the process. Putting too much thought into how to do something will eventually result in stress.

Keep organized!

Being organized shows you are in control and prevents events clashing, therefore stressful situations are avoided. Knowing what to do and how to do it saves a lot of energy. Having an organized plan is relaxing, motivating, and plays a key role in improving your productivity.

Moreover, improved productivity can act as a boost for self-esteem. Being organized allows you to allocate time to yourself, too.

9 What's the difference between fatigue and lethargy?

Fatigue is a physical condition that results from exhaustion, while lethargy is a mental health issue portrayed by persistent exhaustion or drowsiness.

Generally, lethargy is a condition that is as a result of low energy levels.

Fatigue has one cause: exhaustion. Lethargy has a variety of causes that range from incorrect diet to lack of proper rest.

10 Lethargy in dogs

In general, dogs are energetic, full of high spirits, and naturally curious. Their levels of energy can wave in an unusual manner depending on several factors, such as the levels of wellness and fitness, diet, and the stimulation levels that they acquire from you, their owner. If you suddenly detect variation in your dog’s energy, it could be life-threatening, particularly if they seem sleepy and exhausted very often time.

Frequent lethargy in dogs is an indication that should not be ignored by any pet owner. Any dog suffering from lethargy could be letting you know that something is unwell. In this event, a heedful observation is needed, and a knowledgeable and skillful veterinarian will examine other symptoms and locate the issue.

Reasons for your dog being lethargic

Lethargy in dogs presents itself emotionally and physically. The dog portrays limited or no concern in what is taking place around him or her, and there is always a detectable response delay to outside stimuli, which includes touch, sight, sound or smell. Do you find your dog quiet and inactive when you get home? Does your dog refuse to eat during usual mealtime? These are some signs of a lethargic dog.

Both physical and mental factors can make a dog lethargic. Some of the possible reasons why your dog may be lethargic include the following.

Infection: Any type of infection including those that are life-threatening such as parvovirus, leptospirosis, distemper, kennel cough , and heartworm illness can cause lethargy in dogs.

• Parvovirus is spread through the feces. Symptoms include lethargy, diarrhea , vomiting, and pain in the abdomen. Treatment involves intense supportive care accompanied by fluids, anti- nausea medicines, and antibiotics.
• Distemper symptoms include fever , lethargy, eye and nose discharge, and coughing. It can stimulate neurological disorders. Distemper signs are wide and differ from one dog to another. Treatment includes the use of antibiotics, anticonvulsants, and fluids.
• Kennel cough can be defined as a contagious respiratory illness where the most typical symptom includes a dry cough . Dogs suffering from kennel cough are lethargic and feverish. Treatments include cough suppressants, bronchodilators, and antibiotics.
• Heartworm disease is induced by heartworms, which get into your dog via the bites of a mosquito. Heartworm infection symptoms include depression, lethargy, fever , and weakness . The best option is to prevent the disease using injectable or oral medications. Treatment can include injections and a period of isolated rest.
• Metabolic and organic illness: Many other chronic conditions can make your dog lethargic. These can include heart conditions, liver defects, hypoglycemia , and diabetes .
• Cardiovascular disease:  Lethargy, loss of appetite, rapid breathing, and reduced tolerance for exercise are some of the signs of congestive heart failure in dogs. Treatment relies on advancement of the condition and can include diuretics, heart medicines, and changes in diet.
• Liver disease : The indications of liver issues in dogs are lethargy, jaundice, appetite deprivation, depression, and the bloating of the abdomen. Liver treatment is vital and may involve drugs, changes in diet, or surgery.
• Diabetes mellitus: The Signs include unreasonable thirst, weight loss, and appetite variation. The treatment involves insulin injections together with diet modifications.
• Hypoglycemia  is a condition that is characterized by low levels of blood sugar. The signs include weakness in dogs, which leads to seizures. Treatment relies on the cause of hypoglycemia. The short-run medical aid includes oral corn syrup or injecting glucose intravenously.

Other problems can cause lethargy in dogs, such as trauma, snake bite, tumour, pain, anaemia, hormonal defects, poisoning from food, and many others.

Call your vet immediately if you detect signs of lethargy.

Steps to take after discovering that your dog is lethargic

Lethargy in dogs is substantial evidence that they require your assistance. Do not brush it off. Check other abnormal behaviors and other indications to locate the cause of the condition. If the dog does not get better in 24 hours, consider medical assistance. The veterinarian conducts various tests such as a blood count examination, chemical urine analysis, x-rays, biochemical profile, and a fecal exam.

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Am Fam Physician. 2023;108(1):58-69

Patient information: See related handout on myalgic encephalomyelitis/chronic fatigue syndrome .

Published online June 6, 2023.

Author disclosure: No relevant financial relationships.

Fatigue is among the top 10 reasons patients visit primary care offices, and it significantly affects patients' well-being and occupational safety. A comprehensive history and cardiopulmonary, neurologic, and skin examinations help guide the workup and diagnosis. Fatigue can be classified as physiologic, secondary, or chronic. Physiologic fatigue can be addressed by proper sleep hygiene, a healthy diet, and balancing energy expenditure. Secondary fatigue is improved by treating the underlying condition. Cognitive behavior therapy, exercise therapy, and acupuncture may help with some of the fatigue associated with chronic conditions. Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, severe, and potentially debilitating disorder with demonstrated inflammatory, neurologic, immunologic, and metabolic abnormalities. ME/CFS has a poor prognosis, with no proven treatment or cure. It may become more common after the COVID-19 pandemic because many patients with long COVID (post–COVID-19 condition) have symptoms similar to ME/CFS. The most important symptom of ME/CFS is postexertional malaise. The 2015 National Academy of Medicine diagnostic criteria diagnose ME/CFS. Exercise can be harmful to patients with ME/CFS because it can trigger postexertional malaise. Patients should be educated about pacing their activity not to exceed their limited energy capacity. Treatment should prioritize comorbidities and symptoms based on severity.

Fatigue is one of the top 10 reasons for a visit to primary care and is reported by 5% to 10% of patients in the primary care setting. 1 , 2 Fatigue is the most common symptom reported by those with chronic illness. 3 A cross-sectional survey found up to 38% of U.S. workers reported fatigue during the previous two weeks. 4 Fatigue is strongly associated with absenteeism, decreased work productivity, and serious accidents. 5 , 6 Fatigue is estimated to cost employers more than $100 billion per year. 4 Risk factors for fatigue in the general population include being female, unmarried, younger, and of lower educational attainment. 7 Fatigue is an important component of frailty syndrome, which is commonly found in older patients with limited physiologic reserves and vulnerability to minor illness or injury, and independently predicts falls and functional decline in older people. 8 – 10 Decreased cognition, some forms of cancer, metabolic and reproductive health effects, and increased mortality have been associated with fatigue. 9 , 11

Fatigue encompasses a range of potential causes and related comorbidities and is a feeling of weariness or exhaustion. 12 This can be a physiologic, self-limited, normal response in healthy individuals. It may also be chronic or secondary to another condition. Fatigue may or may not respond to rest. In comparison, sleepiness is the tendency to doze off and responds to rest. 13 Patients, physicians, and medical journals use the words fatigue, sleepiness, and weakness interchangeably; the three are often related and not mutually exclusive. There are widely used objective and subjective tools to assess and monitor sleepiness. 13 In contrast, assessment tools for fatigue are not consistently validated and tend to be condition specific. 14

The differential diagnosis list for fatigue is extensive ( Table 1 ) . 15 , 16 Table 2 provides a list of questions to ask when eliciting a history from a patient with fatigue. 16 Physicians should use validated screening tools to rule out comorbid sleep, mood, and substance use disorders. Figure 1 suggests an approach to evaluating patients with fatigue. Medications should be reviewed to ensure the fatigue is not iatrogenic. A physical including cardiopulmonary, neurologic, and skin examinations should be performed. The initial laboratory workup should be guided by history, physical examination, and common causes of fatigue. Laboratory testing without specific indications is not high-yield and may only change treatment in 5% of patients. 17

Despite a comprehensive workup, a definitive diagnosis is often not made. In one study investigating first-time reports of fatigue in young adults without known comorbid conditions presenting to primary care, most received a workup; however, only 27% were diagnosed with a condition that could explain the fatigue, the most common of which included anemia, vitamin B 12 deficiency, infection, pregnancy, and psychiatric diagnoses. 17 In another study, only 8% of patients received a clear condition-based diagnosis one year after their presentation to primary care with fatigue. Nearly 17% received a psychological diagnosis. 18

Physiologic Fatigue

Physiologic fatigue, caused by an imbalance between activities that burn energy and those that restore energy, is a normal response relieved by appropriate rest. Physiologic causes of fatigue should be assessed before investigating secondary or chronic fatigue. 15 , 16 , 19 Physicians should inquire about the patient's daily habits, including the amount and quality of sleep, activity level throughout the day, and nutritional status. Inadequate sleep is a widespread problem, with nearly 30% of U.S. adults reporting fewer than seven hours of sleep per night. 20 Patients at high risk of obstructive sleep apnea should be screened using a validated tool such as the STOP-Bang (snoring, tiredness, observed apnea, blood pressure, body mass index, age, neck circumference, gender) questionnaire. 21 Good sleep hygiene can contribute to more restorative sleep. Patients should be reminded to adhere to consistent sleep schedules, limit screen time, and avoid caffeine and alcohol near bedtime. 22 Excessive exercise of prolonged intensity and duration that depletes energy stores and does not allow for adequate recovery can leave patients feeling fatigued. 23 A prerequisite to having the energy to perform daily tasks is consuming the nutritional components to create this energy. Physicians should ask patients about their dietary habits and counsel them to avoid fad diets or excessively restrictive meal regimens. Ginseng may be helpful with nonspecific physiologic fatigue. 24

Secondary Fatigue

Fatigue is a common symptom of many disorders. Treatment should target the underlying condition. For example, pulmonary rehabilitation helps the respiratory symptoms of chronic obstructive pulmonary disease and also fatigue. 25 Exercise therapy and psychological interventions, specifically cognitive behavior therapy, have some evidence of effectiveness in fatigue related to cancer, 26 inflammatory conditions (e.g., rheumatoid arthritis, inflammatory bowel disease), 27 , 28 and neurologic conditions (e.g., multiple sclerosis, myasthenia gravis). 29 , 30 Exercise may improve fatigue and function related to fibromyalgia. 31 , 32 Tai chi may be superior to aerobic exercise for those with fibromyalgia. 33 Massage and acupuncture may help manage cancer-related fatigue. 34 , 35 There is no evidence that pharmacologic treatment targeting fatigue (e.g., modafinil, methylphenidate) helps manage fatigue related to most chronic diseases. 36 , 37

Chronic Fatigue

Fatigue lasting six months or longer is considered chronic. Many common diseases are associated with chronic fatigue. 15 Most people with protracted fatigue do not have chronic fatigue syndrome. 18 However, when a patient has fatigue for six months or longer, and physiologic and secondary causes are excluded, physicians should consider a diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

ME/CFS is a chronic, complex, multisystem, incompletely understood, and variably defined condition with a poor prognosis. 15 In 2015, the National Academy of Medicine renamed the condition and published recommendations with evidence-based diagnostic criteria 16 , 19 , 38 ( Table 3 16 , 19 ) . The diagnostic criteria have been widely adopted; however, the name systemic exertional intolerance disease is not commonly used. 15 , 16

An ME/CFS diagnosis requires the patient to experience severe fatigue that produces a substantial decrease from pre-illness function. The secondary fatigue associated with most chronic diseases improves with exercise. In contrast, patients with ME/CFS can experience a prolonged worsening of symptoms with even a small increase in a previously tolerated activity. This is called postexertional malaise 15 , 16 ( Table 4 15 , 19 ) . Patients refer to it as a crash or relapse. Postexertional malaise can be provoked by physical exertion but also by challenges in the emotional, cognitive, and sensory realms. The symptoms of postexertional malaise are far more severe than expected from simple overexertion by a patient who is not physically fit. Postexertional malaise is the most important feature of ME/CFS and distinguishes it from other fatigue-causing conditions.

There are no physical examination findings or diagnostic tests for ME/CFS. It was previously a diagnosis of exclusion but now is a clinical diagnosis 16 , 39 ( Figure 2 19 ) . ME/CFS is not a psychological disorder and is not caused by physical deconditioning, laziness, or malingering. Patients with this disorder have debilitating symptoms and frequently face stigma and skepticism from friends, family, and physicians. 40 Patients often know more about ME/CFS than their physicians, and many have little trust in the medical establishment. 41

ME/CFS may be difficult to diagnose due to an extensive differential, variable clinical presentations, multiple possible comorbid conditions, and a lack of medical education and awareness among physicians 42 ( Table 1 15 , 16 ) . Any condition associated with chronic fatigue, chronic pain, autonomic dysfunction, or immune dysregulation can overlap with ME/CFS and cloud the clinical picture.

EPIDEMIOLOGY

ME/CFS may affect 0.8% to 2.2% of the U.S. population, but most are undiagnosed or misdiagnosed. 43 The COVID-19 pandemic may increase the prevalence because many patients with long COVID (post–COVID-19 condition) report long-lasting sequelae, including chronic fatigue. 44 Women are affected three to four times more often than men. 43 Most patients are White, but prevalence data are lacking in people of color. 15 The patient's age at diagnosis is bimodal, with a peak in the teenage years and another peak in the thirties, but the condition has been described in people from two to 77 years of age. 16

Patients with ME/CFS and their family members report worse function and quality of life scores than patients with other severe chronic diseases such as multiple sclerosis. 45 , 46 The severity of illness varies, with 25% of patients able to work. Between 10% and 25% are homebound or bedbound. 47 The most severely affected patients often cannot access medical care and are usually not included in studies of ME/CFS. Other patients have waxing and waning symptoms and functional status. 47

PATHOPHYSIOLOGY

Researchers have found abnormalities in energy metabolism in the nervous and immune systems in patients with ME/CFS. 15 , 48 Patients exhibit impaired generation and utilization of adenosine triphosphate, the key energy-storing molecule in aerobic metabolism. 49 When patients underwent maximal exercise over two consecutive days, the patients with ME/CFS demonstrated significantly impaired exercise performance on day 2 compared with healthy participants and even patients with multiple sclerosis. 50

MEDICAL CARE

There is no U.S. Food and Drug Administration–approved treatment for ME/CFS. 51 The most valuable action a physician can take for a patient with this disorder is to validate their concerns. 15 , 16 A healthy patient-physician relationship is only possible when the patient feels believed. The physician should treat symptoms in order of severity, with the patient setting the priority 19 ( Table 5 15 , 16 , 51 – 53 ) . The goal of treatment should be to minimize symptoms and maximize function, which may include facilitating access to resources available to any severely disabled patient. Physicians should treat any comorbidities and educate patients about pacing, where the patient stays within their finite energy capacity to avoid triggering postexertional malaise. Patients can use the mantra “Stop, rest, pace.” 15 , 16 , 19 , 54 , 55 Helpful pacing resources can be found at https://www.meaction.net/resource/pacing-and-management-guide . 54 The Centers for Disease Control and Prevention website provides patient-centered handouts at https://www.cdc.gov/me-cfs/resources/patient-toolkit.html . 55

Treatment must be individualized because every patient with ME/CFS has different symptoms. Polypharmacy can become a problem, so using medications with more than one therapeutic effect is helpful (e.g., prescribing a tricyclic antidepressant to help with both poor sleep and pain). Frequent medication reconciliation is imperative. Patients may be sensitive to adverse medication effects; therefore, lower doses to start should be considered and increased slowly as indicated.

Regularly scheduled visits foster the patient-physician partnership and help continually reassess and optimize symptom-directed therapy. Physicians should offer telemedicine visits because even an outing to a physician's office may trigger postexertional malaise. Because many of these patients are homebound, telemedicine can help them access much-needed care. Specialists should be consulted as needed and could include psychology, pain medicine, physiatry, occupational therapy, physiotherapy, and sleep medicine. 52

OUTDATED RECOMMENDATIONS AND CONTROVERSY

In 2011, the PACE trial reported that graded exercise therapy and cognitive behavior therapy were effective treatments for patients with ME/CFS. 56 The study was later found to have significant methodologic flaws and investigator-related conflicts of interest. 57 Reanalyzed data showed no benefit of interventions and showed harms in the graded exercise therapy group. 58 Importantly, exercise is no longer recommended by the U.S. ME/CFS Clinician Coalition and is likely to be harmful compared with standard care. 15 , 16 , 59 Cognitive behavior therapy may be as helpful as it would be for anyone with a chronic debilitating disease, but it does not help with fatigue.

This article updates previous articles on this topic by Yancey and Thomas , 60 Rosenthal, et al. , 61 and Craig and Kakumanu . 62

Data Sources: A search was completed in PubMed using the key terms fatigue, sleepiness, screening for obstructive sleep apnea, myalgic encephalomyelitis/ chronic fatigue syndrome. Additional terms included prevalence, diagnosis, treatment, prognosis, definition, measurement, cost, and productivity. Essential Evidence Plus and the Cochrane database were also searched in addition to reference lists in retrieved articles. Priority included articles published since 2012 and focused on meta-analyses, systematic reviews, specialty society guidelines, and randomized controlled trials. Search dates: June 2022, July 2022, November 2022, and April 2023.

Finley CR, Chan DS, Garrison S, et al. What are the most common conditions in primary care? Systematic review. Can Fam Physician. 2018;64(11):832-840.

Nicholson K, Stewart M, Thind A. Examining the symptom of fatigue in primary care: a comparative study using electronic medical records. J Innov Health Inform. 2015;22(1):235-243.

Nordin Å, Taft C, Lundgren-Nilsson Å, et al. Minimal important differences for fatigue patient reported outcome measures–a systematic review. BMC Med Res Methodol. 2016;16:62.

Ricci JA, Chee E, Lorandeau AL, et al. Fatigue in the U.S. workforce: prevalence and implications for lost productive work time. J Occup Environ Med. 2007;49(1):1-10.

Enns MW, Bernstein CN, Kroeker K, et al.; CIHR Team in Defining the Burden and Managing the Effects of Psychiatric Comorbidity in Chronic Immunoinflammatory Disease. The association of fatigue, pain, depression and anxiety with work and activity impairment in immune mediated inflammatory diseases. PLoS One. 2018;13(6):e0198975.

Gaines AR, Morris MB, Gunzelmann G. Fatigue-related aviation mishaps. Aerosp Med Hum Perform. 2020;91(5):440-447.

Junghaenel DU, Christodoulou C, Lai JS, et al. Demographic correlates of fatigue in the US general population: results from the patient-reported outcomes measurement information system (PROMIS) initiative. J Psychosom Res. 2011;71(3):117-123.

Zengarini E, Ruggiero C, Pérez-Zepeda MU, et al. Fatigue: relevance and implications in the aging population. Exp Gerontol. 2015;70:78-83.

Knoop V, Cloots B, Costenoble A, et al.; Gerontopole Brussels Study Group. Fatigue and the prediction of negative health outcomes: a systematic review with meta-analysis. Ageing Res Rev. 2021;67:101261.

Pana A, Sourtzi P, Kalokairinou A, et al. Association between self-reported or perceived fatigue and falls among older people: a systematic review. Int J Orthop Trauma Nurs. 2021;43:100867.

Lock AM, Bonetti DL, Campbell ADK. The psychological and physiological health effects of fatigue. Occup Med (Lond). 2018;68(8):502-511.

Walters SJ, Stern C, Stephenson M. Fatigue and measurement of fatigue: a scoping review protocol. JBI Database System Rev Implement Rep. 2019;17(3):261-266.

Shahid A, Shen J, Shapiro CM. Measurements of sleepiness and fatigue. J Psychosom Res. 2010;69(1):81-89.

Machado MO, Kang NC, Tai F, et al. Measuring fatigue: a meta-review. Int J Dermatol. 2021;60(9):1053-1069.

Bateman L, Bonilla H, Dempsey Tet alU.S. ME/CFS Clinician Coalition. Diagnosing and treating myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Version 2. July 2020. Accessed March 29, 2023. https://mecfscliniciancoalition.org/wp-content/uploads/2021/06/MECFS-Clinician-Coalition-Diagnosis-and-Treatment-Handout-V2.pdf

Bateman L, Bested AC, Bonilla HF, et al. Myalgic encephalomyelitis/chronic fatigue syndrome: essentials of diagnosis and management. Mayo Clin Proc. 2021;96(11):2861-2878.

Kitai E, Blumberg G, Levy D, et al. Fatigue as a first-time presenting symptom: management by family doctors and one year follow-up. Isr Med Assoc J. 2012;14(9):555-559.

Nijrolder I, van der Windt D, de Vries H, et al. Diagnoses during follow-up of patients presenting with fatigue in primary care. CMAJ. 2009;181(10):683-687.

Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome; Board on the Health of Select Populations; Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness . National Academies Press; 2015.

Centers for Disease Control and Prevention. Perceived insufficient rest or sleep among adults—United States, 2008. MMWR Morb Mor tal Wkly Rep. 2009;58(42):1175-1179.

Nagappa M, Liao P, Wong J, et al. Validation of the STOP-BANG questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One. 2015;10(12):e0143697.

Sleep Foundation. Insomnia. Updated March 3, 2023. Accessed April 20, 2023. https://www.sleepfoundation.org/insomnia

da Rocha AL, Pinto AP, Kohama EB, et al. The proinflammatory effects of chronic excessive exercise. Cytokine. 2019;119:57-61.

Arring NM, Millstine D, Marks LA, et al. Ginseng as a treatment for fatigue: a systematic review. J Altern Complement Med. 2018;24(7):624-633.

Van Herck M, Antons J, Vercoulen JH, et al. Pulmonary rehabilitation reduces subjective fatigue in COPD: a responder analysis. J Clin Med. 2019;8(8):1264.

Mustian KM, Alfano CM, Heckler C, et al. Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: a meta-analysis. JAMA Oncol. 2017;3(7):961-968.

Cramp F, Hewlett S, Almeida C, et al. Non-pharmacological interventions for fatigue in rheumatoid arthritis. Cochrane Database Syst Rev. 2013(8):CD008322.

Emerson C, Barhoun P, Olive L, et al. A systematic review of psychological treatments to manage fatigue in patients with inflammatory bowel disease. J Psychosom Res. 2021;147:110524.

Ruiter AM, Verschuuren JJGM, Tannemaat MR. Fatigue in patients with myasthenia gravis. A systematic review of the literature. Neuromuscul Disord. 2020;30(8):631-639.

Chen Y, Xu S, Shen J, et al. Effect of exercise on fatigue in multiple sclerosis patients: a network meta-analysis. Int J Sports Med. 2021;42(14):1250-1259.

Estévez-López F, Maestre-Cascales C, Russell D, et al. Effectiveness of exercise on fatigue and sleep quality in fibromyalgia: a systematic review and meta-analysis of randomized trials. Arch Phys Med Rehabil. 2021;102(4):752-761.

Merriwether EN, Frey-Law LA, Rakel BA, et al. Physical activity is related to function and fatigue but not pain in women with fibromyalgia: baseline analyses from the Fibromyalgia Activity Study with TENS (FAST). Arthritis Res Ther. 2018;20(1):199.

Wang C, Schmid CH, Fielding RA, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. 2018;360:k851.

Zhang Y, Lin L, Li H, et al. Effects of acupuncture on cancer-related fatigue: a meta-analysis. Support Care Cancer. 2018;26(2):415-425.

Kinkead B, Schettler PJ, Larson ER, et al. Massage therapy decreases cancer-related fatigue: results from a randomized early phase trial. Cancer. 2018;124(3):546-554.

Fabi A, Bhargava R, Fatigoni S, et al.; ESMO Guidelines Committee. Cancer-related fatigue: ESMO clinical practice guidelines for diagnosis and treatment. Ann Oncol. 2020;31(6):713-723.

Nourbakhsh B, Revirajan N, Morris B, et al. Safety and efficacy of amantadine, modafinil, and methylphenidate for fatigue in multiple sclerosis: a randomised, placebo-controlled, crossover, double-blind trial. Lancet Neurol. 2021;20(1):38-48.

Haney E, Smith MEB, McDonagh M, et al. Diagnostic methods for myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review for a National Institutes of Health Pathways to Prevention workshop. Ann Intern Med. 2015;162(12):834-840.

Fukuda K, Straus SE, Hickie I, et al.; International Chronic Fatigue Syndrome Study Group. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121(12):953-959.

Jason LA, Richman JA. How science can stigmatize: the case of chronic fatigue syndrome. J Chronic Fatigue Syndr. 2007;14(4):85-103.

Lacerda EM, McDermott C, Kingdon CC, et al. Hope, disappointment and perseverance: reflections of people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and multiple sclerosis participating in biomedical research. A qualitative focus group study. Health Expect. 2019;22(3):373-384.

Hng KN, Geraghty K, Pheby DFH. An audit of UK hospital doctors' knowledge and experience of myalgic encephalomyelitis. Medicina (Kaunas). 2021;57(9):885.

Lim EJ, Ahn YC, Jang ES, et al. Systematic review and meta-analysis of the prevalence of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). J Transl Med. 2020;18(1):100.

Mirin AA, Dimmock ME, Jason LA. Updated ME/CFS prevalence estimates reflecting post-COVID increases and associated economic costs and funding implications. Fatigue. 2022;10(2):83-93.

Kingdon CC, Bowman EW, Curran H. Functional status and well-being in people with myalgic encephalomyelitis/chronic fatigue syndrome compared with people with multiple sclerosis and healthy controls. Pharmacoecon Open. 2018;2(4):381-392.

Vyas J, Muirhead N, Singh R, et al. Impact of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) on the quality of life of people with ME/CFS and their partners and family members: an online cross-sectional survey. BMJ Open. 2022;12(5):e058128.

Conroy K, Bhatia S, Islam M, et al. Homebound versus bedridden status among those with myalgic encephalomyelitis/chronic fatigue syndrome. Healthcare (Basel). 2021;9(2):106.

Komaroff AL. Advances in understanding the pathophysiology of chronic fatigue syndrome. JAMA. 2019;322(6):499-500.

Wirth KJ, Scheibenbogen C. Pathophysiology of skeletal muscle disturbances in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). J Transl Med. 2021;19(1):162.

Hodges LD, Nielsen T, Baken D. Physiological measures in participants with chronic fatigue syndrome, multiple sclerosis and healthy controls following repeated exercise: a pilot study. Clin Physiol Funct Imaging. 2018;38(4):639-644.

Smith MEB, Haney E, McDonagh M, et al. Treatment of myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review for a National Institutes of Health Pathways to Prevention workshop. Ann Intern Med. 2015;162(12):841-850.

National Institute for Health and Care Excellence. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. NICE Guideline, No. 206. October 29, 2021. Accessed March 29, 2023. https://www.ncbi.nlm.nih.gov/books/NBK579533/#!po=0.375940

Polo O, Pesonen P, Tuominen E. Low-dose naltrexone in the treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Fatigue. 2019;7(4):207-217.

Myalgic Encephalomyelitis Action Network. Pacing and management guides. Accessed March 28, 2023. https://www.meaction.net/resource/pacing-and-management-guide

Centers for Disease Control and Prevention. Myalgic encephalomyelitis/chronic fatigue syndrome: treatment of ME/CFS. January 28, 2021. Accessed March 28, 2023. https://www.cdc.gov/me-cfs/treatment/index.html

White PD, Goldsmith KA, Johnson AL, et al.; PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377(9768):823-836.

ST A T. Rehmeyer J. Bad science misled millions with chronic fatigue syndrome. Here's how we fought back. September 21, 2016. Accessed July 11, 2022. https://www.statnews.com/2016/09/21/chronic-fatigue-syndrome-pace-trial

Virology Blog. Tuller D. Trial by error: the troubling case of the PACE chronic fatigue syndrome study. Accessed July 31, 2022. https://www.virology.ws/2015/10/21/trial-by-error-i

Larun L, Brurberg KG, Odgaard-Jensen J, et al. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev. 2019(10):CD003200.

Yancey JR, Thomas SM. Chronic fatigue syndrome: diagnosis and treatment. Am Fam Physician. 2012;86(8):741-746.

Rosenthal TC, Majeroni BA, Pretorius R, et al. Fatigue: an overview. Am Fam Physician. 2008;78(10):1173-1179.

Craig T, Kakumanu S. Chronic fatigue syndrome: evaluation and treatment. Am Fam Physician. 2002;65(6):1083-1090.

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• History of Present Illness

Review of Systems

• Past Medical History
• Physical Examination
• Differential Diagnoses
• Relevant Testing
• Test Results 1
• Test Interpretation
• Diagnosis 1
• Relevant Next Steps
• Test Results 2
• Diagnosis 2
• Treatment Orders
• About the Case

Chronic lethargy in a 68 yo woman

• General : The patient says she feels tired all the time and is usually cold even now during the summer. She has a poor appetite but has gained 5 kg in weight in the preceding 4 mo despite decreased appetite. No fever, chills, headache, or body aches.
• Skin : Her skin has become dry, and her hair is now coarse and sparse. No rash or itching.
• HEENT : She reports fullness in her throat, and her daughter has noticed that her mother’s voice has become hoarse and her face appears puffy, particularly around the eyes. No difficulty swallowing.
• Pulmonary : The patient reports new exertional shortness of breath and needing to pause after climbing ½ flight of stairs. No cough or wheezing.
• Cardiovascular : She used to have occasional palpitations before but has had none for the last 2 mo. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea.
• Gastrointestinal : The patient’s bowel movements have decreased from daily to once every 3 to 4 days when using laxatives. She does not have any abdominal pain or vomiting. Her appetite is decreased.
• Genitourinary : Noncontributory
• Musculoskeletal : Her ankles and lower legs are more swollen than they used to be. She reports fatigue and leg weakness when climbing stairs or getting up from a chair.
• Neurologic : She has become slower at performing daily activities, and extra effort is required. Her daughter has noticed that her mother has trouble remembering recent events, such as whether she has taken her medications. She denies having focal weakness or sensory abnormalities, tremor, or visual symptoms.
• Psychiatric : Her mood is depressed and she often stays in bed, not going out of the house for many days.

Chapter 4 . John’s Case: Acing Tests and Buying Guitars

4.1 screen 1.

Author: Taryn A. Myers, Virginia Wesleyan College

4.2 Screen 2

Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session, or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.

4.3 Screen 3

The receptionist hands you the intake paperwork prior to your intake interview with your new client, John, and mentions that his parents have brought him in. They seem very worried about their son. Click on the button below to review the paperwork before you begin the interview.

New Client John: Case #10108

Psychological Clinic

Intake Paperwork

Client Name: John

Age: 20 years old

Gender: Male

Ethnicity: Caucasian

Occupation: College student

Current living situation: I live in an off-campus apartment with my roommate.

Why are you seeking services at our clinic?

My parents brought me here. They say they are worried about me. I’m not sure why they are freaking out so much. I feel like I have had a personality transplant. I do not feel like myself, and I am having a hard time concentrating, but I don’t think I am as sick as my parents think I am.

4.4 Screen 4

You will now ask John and his parents a number of questions you would typically ask during the intake interview. As you conduct the interview with John, begin to think about his symptoms, what his diagnosis might be, and later, what type of treatment might be most helpful to John. Click the “play” button below the illustration to hear John’s and his parent’s responses to your questions. To read the transcript for these answers, click on the “transcript” button. Take notes in the box provided as you listen to John’s responses.

4.5 Screen 5

"Hi John. It’s good to meet you and your parents. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean continuing to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today."

John[speaking very quickly]: My parents made me come. I don’t really know why. The only thing I can think of is [pauses]… I feel like I’ve had a complete personality transplant, maybe in like the last few weeks or so. I don’t think I’m a super creative or original person, but all of the sudden I have, like, so many ideas about ways I could improve my life... ideas for new projects.... [interrupts himself] like, I had this awesome idea! I am going to start a business buying and selling musical equipment on Craigslist. So I bought a bunch of old guitars online. I’m going to fix them up and resell them for a profit. Problem is... I used my credit card to buy them… and my parents found out because they get the bill. [turns to parents, somewhat angrily] They don’t believe in me at all! They can’t see what a great idea this is! I was going to fix them up before they got the bill, but then I got an even better idea! I was watching TV late one night... I don’t really need much sleep these days... and I saw this great opportunity! I could become an online advertising salesrep! I had to pony up a bit more cash up front for that, so I put that on the credit card too, but it’s totally fine… totally... I know it’s a “sure thing” and I’ll be able to make this money back and then some before the next payment is due.

Mom[quietly with concern]: We are really concerned. John has been acting strangely lately. And then we got the bill for the credit card we cosigned for John – and this was for emergencies only! And the bill was over $2,500!

Dad[jumps in, sounding incredulous]: He spent over $1000 online for these old guitars. When I asked him about it, he told me he was going to refurbish them and resell them for a profit. Now, John has always enjoyed playing the guitar as a hobby, and he’s pretty darn good at it, but he has never actually refurbished anything. I don’t even think he owns any tools!

Mom[breaking in]: And then the online advertising thing!

Dad: That was another $1,500! He tried to tell us it was a “sure thing”; that he would have a profit before the payment was due. Well, it’s due tomorrow, and he has yet to bring in a cent!

Mom[upset]: He was always so careful with money in the past. What’s happening, John?

Question 4.1

Check Your Notes

- Client brought in by his parents - Notes that he feels he has a “personality transplant”

• Duration: last few weeks

- Ideas and projects – change from the past (not normally creative)

• Fix up and resell guitars
• Mounting charges on parents’ credit card / parents alerted by large bill
• Opportunity to become online advertising salesrep –charged $1500 fee – “sure thing”

- Reports needing much less sleep John’s parents: - Very concerned with son’s strange behavior - Rung up a lot of money on “emergency-only” credit card - Used to be “cautious with money” - Musical and plays guitar - Not very handy; doesn’t own tools - John claims business venture is a “sure thing”; parents report that he has not earned anything yet; - Credit card charges mounting; bill due tomorrow

4.6 Screen 6

"That sounds difficult for all of you. John, what other concerns are you having at this time?"

John[speaking quickly and sounding annoyed]: None! I really don’t understand why I am here. Other people have a problem, not me. Everyone else is moving in slow motion … I don’t have time to wait around for them to “get it.” Why can’t they just keep up? Why can’t they just believe in me? I told Calvin ... he’s my roommate … my ideas about the guitars, and he was such a jerk about it– he kept pointing out things he said could go wrong. And mom and dad don’t understand me – they even asked if I am on drugs![contemptuous] On drugs! Don’t you guys even trust me? Don’t you get that I’m finally seeing the world clearly?

Mom[trying to be empathetic and sensible]: Calvin says that you are talking a mile a minute! He said it seems like you’re having a hard time getting all of your ideas out. Calvin is really worried about you, John. He is worried that you are wasting your money!

Dad[breaking into back up Mom]: You were talking so fast, son! I could barely understand what you were saying… your words were all garbled. You were just not making sense. It sounded like you were on drugs! Something is going on, John.

Question 4.2

John: - No concerns; other people have problems - Everyone else in slow motion; they can’t keep up with him - Roommate points out problems with John’s plans - Parents suspect drug use Parents: - John is talking very quickly - He has a hard time getting ideas out - They think he sounds like he’s on drugs - They are very concerned with this behavior - They mention that the roommate is also worried

Question 4.3

Think about which symptom could potentially cause serious issues for John down the road.

4.7 Screen 7

"What areas of your life have been affected? How is your schoolwork going?"

John[excited]: School is going great! I’m not worried about my grades. I’ll ace the tests without going to class... I don’t need to do any of those worthless assignments. I tried going to class, but it’s just so boring... [interrupts himself] not to mention a huge waste of time! I could be making money! My friends keep giving me a hard time about it, but they’re just jealous of my ideas and how quickly I can learn things!

Question 4.4

John: - He says school is going well - He is not worried about grades - He is skipping class - Feels his friends are “jealous” → possible grandiosity?

4.8 Screen 8

"Tell me about your sleeping habits. Have you had any difficulty falling or staying asleep?"

John: I don’t get tired any more. I don’t need to sleep. I’m sleeping, like … 2 or 3 hours a night and I wake up feeling great and ready to go! …to work on my next project!

Dad: His roommate told us that John is up most of the night and claims he is not tired. What do you mean you’re not tired? That can’t be healthy! John, you’re going to get even sicker if you don’t get enough sleep!

Question 4.5

Sleeping habits John: - He doesn’t feel a need to sleep - 2-3 hrs of sleep/night is enough for him Parents: - Roommate confirms John’s reported sleep habits - They are worried about John’s health

Question 4.6

4.9 screen 9.

"Have you experienced any psychological symptoms in the past?"

John: I don’t remember. I guess I was depressed once in high school. I can hardly remember that now. I really feel great now!

Mom: I’ve always been a little concerned that John was too sensitive. He used to worry about small things all the time. And then when he was 17…

Dad[breaking into finish Mom’s sentence]: ... that girl broke his heart.

Mom[sadly, reminiscing]: He had been dating her for an entire year. Then she broke it off out of the blue and started dating another boy within a few weeks. John tried so hard to get her back. He left her multiple voicemails and text messages every day. She broke his heart. He just seemed so down. He stopped hanging out with his friends … he always had an excuse not to go to events or parties when they invited him out. He had no appetite and lost weight … something like 15 pounds in only a couple of months. I was so worried about him… John, you looked like you were wasting away.

Dad: We tried to get him to see the doctor.

Mom: Or to talk to someone like you … like a counselor. But he wouldn’t hear of it!

Dad: After a few months, he got over it. He started hanging out with his friends again.

Mom[reminiscing, smiling]: It was so nice to see him laugh and smile again! I was so relieved it was over.

Dad: I was glad he finally got over that girl. She wasn’t worth all that, son.

Question 4.7

John: - Acknowledges that he was depressed once - Asserts that he feels great now Parents: - Mom worried he is too “sensitive” - In high school he dated a girl for a year, but she broke it off - He called and texted her repeatedly - John’s symptoms:

• He seemed “down”
• He stopped hanging out with his friends
• No appetite
• He lost 15 lbs. in 2 months

- He refused to see a doctor or counselor - His sadness lasted a few months

Question 4.8

According to John and his parents, what symptoms did John exhibit when his girlfriend broke up with him? Check all that apply.

4.10 Screen 10

Question 4.9.

Remember that John's symptoms included sadness, loss of interest in usual activities, social isolation, loss of appetite, and weight loss.

4.11 Screen 11

"Tell me about your family. What was it like growing up in your household?"

John: I have a sister, 6 years younger and a little brother, 8 years younger than I am. They’re pretty cool. Growing up, you guys seemed like you didn’t have time for me.

Dad[a little defensively]: Well, we sure didn’t plan to have kids as quickly as we did. We weren't really ready to start a family.

Mom: John was certainly a surprise. We were married – of course! I quit my Master’s program when I had John. When he was two, I had to get a part-time job as an accountant to help out and ended up staying there. Sometimes, I regret that I wasn’t able to finish my degree. But I loved being able to spend time with my kids when they were younger.

Dad: And because I work in the banking industry, we do fine, now. But those first few years were tough.

Mom: After 5 years or so, we felt okay having more kids. I feel like we were able to be much better parents then. I sometimes feel guilty about how difficult things were during your childhood, John.

Question 4.10

John: - Sister, 6 years younger - Brother, 8 years younger - Parents stressed during John’s early childhood - Felt like his parents didn’t have time for him Parents: - John was an unplanned pregnancy Mom: - Quit Master’s program - Worked part time as an accountant - Regrets not finishing master’s program - Enjoyed spending time with her children Dad: - Works as banker - Struggled financially at first - Mom feels guilty → John’s experience was different from his siblings’

Question 4.11

4.12 screen 12.

"John, can you describe your relationship with your parents?"

John: We’re really close. I usually call them at least once a week… I guess I haven’t lately … I’ve just been too busy with all my projects. Still, I don’t understand why they had to jump in the car and drive 2 hours just because my roommate Calvin called them. [To his parents] I mean, c’mon! Don’t you guys trust me anymore?

Question 4.12

Relationship with parents John: - Close relationship with his parents - Talks to them once a week - He has not been calling them lately because of his “projects” - Parents drove 2 hours to see him because they are concerned

Question 4.13

Think about John's communication with his parents.

4.13 Screen 13

"How did John do in school growing up?"

Mom: In school, John was generally an A/B student. He was uncomfortable being the center of attention - he didn’t speak up in class much, but he was very conscientious about his school assignments and rarely missed a day of school.

Dad: He had several close buddies. He’s known these kids since kindergarten. They all hung out together in high school, too.

Question 4.14

Parents: - A/B student - Didn’t talk in class much, introverted - Conscientious in terms of completing assignment and attending school - Had a few close friends - His friends were old friends, from Kindergarten to HS

4.14 Screen 14

"Has anyone in your family ever had a mental health problem?"

John: Not that I know of. My family is awesome. I mean … who isn’t a little nuts? Wait, seriously… wasn’t Grandpa a little crazy?

Mom[nodding in agreement]: My father did have had a lot of trouble with mental problems. He was diagnosed with… [searching for the correct word] what do they call it now… it was called manic-depression… yes, bipolar disorder… I think when he was in his 30’s. He had to be hospitalized. He was on medication, but he stopped taking it sometimes, and then it would be really hard to be around him.

Dad: He had an episode like this around the time John was born.

Mom: It was almost too much for me at the time. It made our lives so stressful, taking care of a young child and trying to care for Dad.

Dad[agreeing]: Those years were really tough.

Mom: I’ve always wondered if John is so shy and serious and melancholy because things were so stressful those first few years.

Question 4.15

John: - Recalls that his grandfather may have had mental problems Parents: - Maternal grandfather → bipolar disorder

• On medication, but occasionally would stop taking his meds
• Stopped taking meds around the time of John’s birth and early childhood
• Added stress to the family dynamic
• Parents took care of John and grandfather

Question 4.16

How could John’s grandfather’s diagnosis have influenced what is happening to John now? More than one answer could be correct. Select all that apply.

Think about the ways in which John’s grandfather’s illness might have directly affected John based on the information you just got from John and his parents.

4.15 Screen 15

Question 4.17.

Think about the concerns John’s parents mentioned at the beginning of the interview.

4.16 Screen 16

"John, do you drink alcohol or use any substances? If so, how much and how often? If you would feel more comfortable, we could ask your parents to leave the room while you answer this question."

John[raising his voice]: They don’t need to leave the room – I want them to hear this! I don’t see how that matters! I am just seeing the world more clearly, and if I go to parties, so what? I’m in college! And Calvin didn’t have any right to call my parents to have them come get me just because he thinks I’m doing drugs. I’m so frustrated with them all. This really ticks me off! Can’t they just leave me alone and let me work on my projects? They’re getting in the way of me making money. I only came here because I feel like I didn’t have a choice… I was sure it would be a huge waste of time. I was obviously right about that one, just like I’m usually right about everything else!

Dad: Your roommate has some real concerns. He says he found you in a separate room at that party on Friday night hanging out with people who are known drug users.

Mom: Calvin said he tried to get you to leave the party with him. He said that you became angry and physically threatened him! Really, John David! I did not raise you to be violent, and Calvin is your friend!

Dad: Calvin called us because he was worried. He said that we should come and get John. Calvin is a good friend, John. That’s a real man who looks out for his friends.

Mom: And then we drive all the way here, and John, you didn’t even get back until all hours of the morning. Where were you? What were you doing, John?

Dad: We made an appointment with the family physician. We are taking him there tomorrow to get him checked out. We had his bags all packed when he finally graced us with his presence at whatever hour of the morning that was. We’re very worried about you, son.

Question 4.18

Alcohol/ substance use John: - Defensiveness about alcohol and drug use, steers discussion to “money making” schemes - Goes to parties → is this normal behavior in college? - Roommate thinks he is doing drugs Parents: - Roommate found John with known drug users - John became violent when roommate tried to make him leave - Roommate called parents - John didn’t return until early in the morning Parents packed his bag, ready to go → worried - They made an appointment with his physician

Question 4.19

Think about John’s symptoms and whether they are mental or physical.

4.17 Screen 17

Question 4.20.

Which of the following symptoms is John currently experiencing? Check all that apply. Use the interview notes to help you remember!

4.18 Screen 18

From the File. You remember a former patient who exhibited symptoms similar to John’s. You review this case to help you diagnose John.

Question 4.21

4.19 screen 19, question 4.22.

Think about the following symptoms John exhibits in making your choice: - Spending money without thinking about the consequences - Feeling like he does not need much sleep - Racing thoughts - Friends noticing his behavior and expressing concern

4.20 Screen 20

Question 4.23.

Review Interview Notes

Think about the types of episodes John has experienced.

4.21 Screen 21

Question 4.24, question 4.25, 4.22 screen 22, question 4.26.

In making your choice, think about the fact that research on the brain and genetics has given us the most helpful information about bipolar disorder in recent years.

Question 4.27

4.23 screen 23, question 4.28, question 4.29, 4.24 screen 24.

As John’s psychologist you referred John to a psychiatrist, Dr. Samuelson, for medication management. In addition, John started meeting with you on a regular basis for cognitive behavioral therapy. Dr. Samuelson put him on lithium and carefully monitored his dosage. Even so, John experienced some side effects, including trouble concentrating, drowsiness, and increased thirst. Also, whenever he began feeling manic, he would want to stop taking the medication. As his therapist, you worked with him on addressing some of his maladaptive thoughts, such as his idea that his manic state was the “real him.” You also encouraged John to analyze his urges not to take his medication. With your help, John was able to use behavioral techniques such as setting a reminder on his phone and using a pill organizer to help him remember to take his medication and settle into a routine.

After taking the rest of the semester off, John returned to school the following semester. He and Calvin made up and continued to live together. John now appreciates Calvin’s previous concern. John tries to remember to call his parents on a regular basis to reassure them that he is doing fine. John decided to major in business so that he can explore and learn to implement some his “entrepreneurial” ideas in realistic ways.

4.25 Screen 25

Real World Application

Watch the following video about how one family struggled with having to involuntarily hospitalize their father due to his bipolar disorder – called “sectioning” in the United Kingdom – and answer the questions below.

Question 4.30

Question 4.31.

Lablogatory

A blog for medical laboratory professionals

Blood Bank Case Study: A 54 Year Old Woman with Lethargy

The patient is a 54 year old woman, presenting to the Emergency Room with complaints of abdominal cramps and feeling lethargic for the past few days. She also reports her stools have been black and sticky.  Her chart reveals a history of ulcers and GI bleeding.  She was transfused with 2 units packed RBCs 2 months ago for the same symptoms. CBC results are shown below.

The patient was admitted to the hospital and four units of blood were ordered. The patient is type A pos with a negative antibody screen. One unit of packed red blood cells would be expected to raise the Hgb by 1g/dl. Because the patient was actively bleeding, 4 units were crossmatched and transfused.

Two days later, the patient was discharged, with orders to follow up with her GI doctor for further testing and treatment. Three days after discharge she still felt weak and returned to the ER. On examination, it was noted that the patient’s eyes and skin appeared jaundiced. The patient had a fever of 100F. Repeat lab results are shown below.

The Physician ordered a type and crossmatch for 2 units of packed red blood cells. The patient’s antibody screen was now positive. A transfusion reaction workup was initiated

Transfusion workup

Clerical Check- No clerical errors found.

Segments from all 4 transfused units were phenotyped for Jka antigen. Three of the four units transfused typed as Jka positive.

A transfusion reaction is defined as any transfusion-related adverse event that occurs during or after transfusion of whole blood, or blood components. Transfusion reactions can be classified by time interval between the transfusion and reaction, as immune or non-immune, by presentation with fever or without fever, or as infectious or non-infectious.

A delayed transfusion reaction is defined as one whose signs or symptoms typically present days to several weeks after a transfusion. In Transfusion Medicine, we do not want to give the patient an antigen that is not present on their red blood cells. However, we do not routinely phenotype patients, so, in the patient with a negative antibody screen and history, it is always possible that the patient receives units with foreign antigens. The more immunogenic the antigen, and the greater number units received that expose the patient to this antigen, the greater likelihood that the patient will develop an antibody to the foreign antigen. Therefore, this type of reaction would also be categorized as immune.

In a delayed hemolytic transfusion reaction (DHTR) investigation, the units transfused would have appeared compatible at initial testing. This type of adverse event is fairly common in patients who have been immunized to a foreign antigen from previous transfusion or pregnancy. The antibody formed may fall to a very low level and therefore not be detected during pretransfusion screening. If the patient is subsequently transfused with another red cell unit that expresses the same antigen, an anamnestic response may occur.  The antibody level rises quickly and leads to the DHTR. In the transfusion reaction workup, this antibody can often be detected when testing is repeated. However, in some cases, particularly with Kidd antibodies, the levels again drop off so quickly they may not be detected!  The diagnosis of DHTR is often difficult because antibodies against the transfused RBCs are often undetectable and symptoms are inconclusive.

This case is a classical example of a DHTR.  Kidd antigens are notorious for causing DHT because their levels can drop off quickly and disappear, making them difficult to detect in screening. In this case, the transfusion two months earlier exposed the patient to the Jka antigen and the patient produced the corresponding antibody. The levels then dropped quickly, as elusive Kidds are known to do! When the patient returned to the ER in crisis, the antibody levels had dropped below detectable levels and the antibody screen was negative. The patient was given 4 units and returned to the ER five days after transfusion. This patient did exhibit mild jaundice and a low-grade fever. However, often, the only symptom of a DHTR is the unexpected drop in Hgb and Hct, making them even more difficult to diagnose.

The new antibody screen, sent to the Blood Bank on day 5, detected anti-Jka. The DAT was positive mixed field due to the transfused cells. Elution was performed and anti-Jka was recovered in the eluate. In the DHTR, only the transfused cells are destroyed. Phenotyping segments from the transfused units can estimate amount of transfused RBCs that may have shortened survival. Management of this case patient would be to provide antigen negative units for all future transfusions.

Kidd  (Anti-Jk a and Anti-Jk b ), Rh, Fy, and K have all been associated with DHTR and occur in patients previously immunized to foreign antigens through pregnancy and transfusion. These types of reactions are generally self-limiting but can be life threatening, especially in multiply transfused patients, such as those with sickle cell anemia. Antigen negative blood must always be given, even if the current sample is not demonstrating the antibody in question. For that reason, it is vitally important to always do a thorough Blood Bank history check on all samples!

-Becky Socha, MS, MLS(ASCP) CM  BB  CM  graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

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3 thoughts on “blood bank case study: a 54 year old woman with lethargy”.

Thanks for sending some Transfusion Medicine cases. Retired from 45 years in the Blood Bank and enjoyed reading them.

Glad you enjoy them. Watch for them every other month!

Thank you Becky Socha, for this interesting case study and I loved your additional information and explanations. I am currently in a BB course for my MLT-MLS program (at APSU) and I have used the basic information from this case for my education. I have cited you and this website, I hope that this will be okay. I now have found this wonderful site for techs and I am excited to read more studies on other subjects. I hope to read more from you again in the future as I explore this amazing blog page!

I was thinking about during this patient’s ER visit with known transfusion history 2 months prior, would it be possible to microhematocrit centrifuge or use hypotonic saline to wash her blood to separate the two cell populations and phenotype both populations to find any discrepancies in different RBC antigens? Also, after 120 days or so when all Donor cells are most likely cleared, she should probably have further testing done to get an accurate antigen and antibody profile, so that when she possibly has another GI bleed in the future, they will have more information on her along with transfusion history.

I have never worked in blood bank yet. I commend all who do as I do not think I could take that kind of pressure. But I find the process both fascinating and complicated/frustrating (with clinically insignificant antibodies causing many issues and interferences in testing!). I am a micro tech at heart, currently working in immunochemistry and general chemistry.

Thank you again! Maya R.

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