Diagnosis of Conversion Disorder
Conversion Disorder Diagnosis: Book Excerpts
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FATIGUE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there weight loss? If there is weight loss, one must consider a neoplasm, endocrine disorders such as hyperthyroidism or diabetes mellitus, malnutrition or malabsorption, and chronic infectious diseases such as tuberculosis or subacute bacterial endocarditis.
- Is there fever? If there is fever, one should consider an infectious disease such as tuberculosis, subacute bacterial endocarditis, toxoplasmosis, infectious mononucleosis, or brucellosis.
- Is there pallor? If there is pallor, the most likely cause is a type of anemia such as that associated with malabsorption syndrome or iron deficiency anemia, pernicious anemia, or anemia blood loss.
- Is the fatigue intermittent or constant? Intermittent fatigue would make one suspect myasthenia gravis. Constant fatigue would be related to any of the conditions we have already discussed. Constant fatigue, however, with no weight loss would make one consider a psychiatric disorder.
- Is there a positive drug or alcohol history? Alcoholism, cocaine abuse, and chronic aspirin ingestion are just a few of the disorders that can be associated with chronic fatigue. Don't forget caffeine abuse!
- Are there associated neurologic findings? Many neurologic disorders are associated with fatigue, and they include muscular dystrophy, amyotrophic lateral sclerosis, and Parkinson's disease.
- Is there polyuria? Polyuria would make one think of hyperthyroidism, diabetes mellitus, hyperparathyroidism, and chronic renal failure.
DIAGNOSTIC WORKUP
All patients should have routine laboratory studies, including CBC, sedimentation rate, chemistry panel, VDRL test, and a urinalysis including analysis for myoglobin. CPK, LDH, AST, and urine creatine and creatinine should be done to rule out muscle disease. A thyroid profile should be done to rule out hyperthyroidism. Further endocrine workup including serum cortisol will help differentiate Addison's disease and hypopituitarism. Because fatigue is associated with aldosteronism, a 24-hr urine aldosterone determination should be done.
Tests for chronic infectious disease, such as febrile agglutinins, brucellin antibody titer, heterophile antibody titer or Monospot test, sputum for AFB, and various skin tests for tuberculosis and fungi, can be done. HIV testing may be appropriate if there is a history of high-risk sexual behavior. Serial blood cultures also would be of value if there is significant fever. Tests for chronic organ failure such as BUN, creatinine, serum electrolytes, and liver function tests should be done. A workup of anemia including a workup of malabsorption syndrome may be necessary. Consequently, stool analysis for fat content as well as
d
-xylose absorption testing may be done.
A search for neoplasm will include chest x-rays, x-rays of the skull and long bones, a bone scan, an upper GI series, and small bowel follow-through as well as a barium enema and intravenous pyelogram. A muscle biopsy will help differentiate certain collagen diseases, muscular dystrophy, and trichinosis. An ANA test and serum complement to screen for collagen disease should be done. A Tensilon test may be necessary to differentiate myasthenia gravis. If a neurologic disease is suspected, referral to a neurologist would be in order. Consider EMG also. If sleep apnea is a possibility, overnight polysomnography is indicated.
If all the tests prove negative, referral to a psychiatrist would be appropriate. On the other hand, it may be appropriate to refer the patient to a psychiatrist earlier in the course of the workup. The diagnosis of chronic fatigue syndrome is sometimes made when all the diagnostic tests are negative, but whether it is truly a disease is questionable.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Fatigue:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Infectious
–Acute viral or bacterial infection
–Chronic infection (e.g., subacute bacterial endocarditis, osteomyelitis, tuberculosis, HIV, viral hepatitis, mononucleosis)
Hematologic
–Anemia
–Thrombotic thrombocytopenic purpura
–Polycythemia vera
Cardiac
–Congestive heart failure
–Congenital heart disease
–Valvular heart disease
–Coronary artery disease
Pulmonary
–COPD
–Obstructive sleep apnea
–Poorly controlled asthma
Endocrine
–Hypothyroidism/hyperthyroidism
–Diabetes, types I and II
–Pregnancy
–Perimenopause
–Addison's disease
Rheumatologic
–Rheumatoid arthritis
–Systemic lupus erythematosus
–Sjögren's syndrome
–Polymyalgia rheumatica
Gastrointestinal
–Inflammatory bowel disease
–Portal hypertension (e.g., cirrhosis)
Acute or chronic renal failure
Neurologic
–Parkinson's disease
–Multiple sclerosis
Psychiatric (e.g., depression, anxiety or panic disorder, anorexia nervosa or bulimia, somatization disorder)
Malignancy
Chronic fatigue syndrome
Fibromyalgia
Tension headache
Primary obesity
Medication side effects (e.g., β-blockers, phenytoin, digitalis, antidepressants, muscle relaxants, hypnotics)
Drug intoxication or withdrawal (e.g., alcohol, opioids, benzodiazepines, barbiturates, cocaine)
Workup and Diagnosis
-
Complete history and physical exam are essential, including screening for malignancy, chronic infection, chronic cardiopulmonary disease, and psychiatric disease
-
Initial workup may include CBC, chemistries, glucose, calcium, urinalysis, liver function studies, TSH, stool guaiac, and age-appropriate cancer screening (e.g., PAP smear, mammography, flexible sigmoidoscopy, PSA)
-
Further testing based on history and physical findings may include chest X-ray (for dyspnea, cough, abnormal lung exam), ECG (for chest pain, dyspnea), echocardiogram (heart murmur), appropriate cultures and/or serology if infection is suspected (e.g., PPD, HIV, hepatitis), malignancy workup, pregnancy test, ANA, ESR, RF, and Lyme titers
-
Further testing based on abnormal initial labs may include anemia workup (reticulocyte count, iron studies, vitamin B12 and folate levels, hemoglobin electrophoresis), hepatitis workup (GGTP, viral hepatitis serologies, ultrasound of the liver), renal ultrasound, bone marrow biopsy, colonoscopy, and thyroid function tests
-
Appropriate imaging studies based on initial workup may include head CT/MRI, abdominal ultrasound or CT, cardiac stress testing, bone X-rays and/or bone scan
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Fatigue:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Inadequate rest
-
Excessive exercise
-
Insufficient caloric intake
-
Depression
-
Infectious mononucleosis: Common in adolescence, typically due to EBV or CMV
-
Anemia
-
Hepatitis
–Viral (e.g., HAV, HBV, HCV)
–Consider autoimmune in adolescent girls
-
Drugs
–Antihistamines, anticonvulsants, opiates
-
Obesity
–Rapid fatigue with exertion
–Somnolence with elevated PaCO2is termed Pickwickian syndrome
-
Tonsillar-adenoidal hypertrophy
–Impaired air exchange while sleeping
–Associated with restless sleeping
-
Chronic fatigue syndrome
–Controversial diagnosis
–Underlying depression is common
-
Polycythemia in neonates can be associated with cyanosis and feeding problems
-
Encephalitis/meningitis
-
Tuberculosis
-
Brucellosis: Weight loss, low-grade fever, back pain
-
Hypothyroidism
-
Adrenocortical insufficiency: Often with hyperpigmentation and weakness
-
Hypoglycemia
-
Inflammatory bowel disease
-
Juvenile rheumatoid arthritis
-
Systemic lupus erythematosus
-
Intussusception
-
Dermatomyositis: Often with muscle weakness and pain
-
Congestive heart failure: With tachypnea and dyspnea on exertion
-
Pericarditis: Fatigue and dyspnea may precede friction rub
-
Renal tubular acidosis
-
Uremia
-
Myasthenia gravis
-
Malignancy
Workup and Diagnosis
-
History
–Duration of complaint
–Sleeping habits (length of sleep, restfulness, snoring)
–Eating habits (number of meals per day, caloric intake)
–Psychosocial stressors
–Associated signs and symptoms (weight change, fever,
-
muscle aches, breathing difficulty, diarrhea, vomiting, sore throat)
–Medications, including over-the-counter drugs
-
Physical exam
–Vital signs and weight
–Oral exam for tonsillar hypertrophy, exudates, erythema
–Palpable lymph nodes
–Hepatomegaly with tenderness
–Splenomegaly (seen with EBV, CMV, lymphoma)
–Skin pallor, jaundice, cyanosis
–Increased work of breathing, wheezes, rales
–Cardiac exam for rubs, murmurs
–Psychological assessment of mood and affect
-
Labs
–Consider screening CBC for anemia
–WBC differential for atypical lymphocytes (in EBV,
CMV) or blasts (in leukemia)
–Viral serology for EBV or CMV
–ALT and AST for hepatitis
–TSH and free T4 for hypothyroidism
–BUN and Cr for renal dysfunction
–Other specific testing based on history, physical exam
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
WEAKNESS AND FATIGUE, GENERALIZED:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs with generalized weakness and fatigue is very important in pinning down a diagnosis. Generalized lymphadenopathy and fatigue suggest infectious mononucleosis, lymphoma, or tuberculosis or other chronic infection such as AIDS. Weakness and weight loss and polyphagia with polyuria and polydypsia would suggest hyperthyroidism or diabetes mellitus. Generalized weakness with polyuria and no significant weight loss suggests hyperparathyroidism. Weakness with pallor suggests some type of anemia. Weakness and weight loss without polyuria or polyphagia suggest malignancy or malabsorption syndrome. Weakness with other significant neurologic signs and symptoms prompts the consideration of muscular dystrophy, amyotrophic lateral sclerosis, or multiple sclerosis. Weakness with drug or alcohol use prompts the investigation of drug or alcohol abuse. Caffeine, especially in large quantities, can also cause significant weakness and chronic fatigue.
The initial workup of weakness and fatigue requires a CBC, sedimentation rate, drug screen, chemistry panel, thyroid profile, ANA, chest x-ray and ECG. If muscular dystrophy or dermatomyositis is suspected, urine for creatinine, creatine and myoglobin can be done. Ultimately, a muscle biopsy may be indicated. If myasthenia gravis is suspected, serum for acetylcholine receptor antibody may be done. If Addison disease is suspected, a serum cortisol may be done. A 24-hour urine aldosterone level may be done to exclude primary aldosteronism. Serum PTH may be done to exclude hyperparathyroidism.
It would be wise to consult an infectious disease specialist before ordering an expensive workup. It would also be wise to consult an oncologist when searching for a malignancy before ordering an expensive workup.
When all tests have negative findings, many clinicians have been tempted to make a diagnosis of chronic fatigue syndrome. It is questionable whether this is truly a disease or not.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Fatigue:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.
Ask about related symptoms and recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and appetite or weight changes. Carefully review the patient’s medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.
Obtain a thorough drug history, noting the use of any drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk for carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector.
Observe the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Gait, bizarre [Hysterical gait]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you suspect that the patient’s gait impairment has no organic cause, begin to investigate other possibilities. Ask the patient when he first developed the impairment and whether it coincided with a stressful period or event, such as the death of a loved one or loss of a job. Ask about associated symptoms, and explore reports of frequent unexplained illnesses and multiple physician’s visits. Subtly try to determine if the patient will gain anything from malingering, for instance, added attention or an insurance settlement.
Begin the physical examination by testing the patient’s reflexes and sensorimotor function, noting abnormal response patterns. To quickly check his reports of leg weakness or paralysis, perform a test for Hoover’s sign: Place the patient in the supine position and stand at his feet. Cradle a heel in each of your palms, and rest your hands on the table. Ask the patient to raise the affected leg. In true motor weakness, the heel of the other leg will press downward; in hysteria, this movement will be absent. As a further check, observe the patient for normal movements when he’s unaware of being watched.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Conversion disorder:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing conversion disorder.
A thorough physical evaluation must rule out a physical cause, especially diseases that typically produce vague physical symptoms (such as multiple sclerosis or systemic lupus erythematosus).
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Chronic fatigue syndrome:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Because the cause and nature of CFS are still unknown, no single test unequivocally confirms its presence. Therefore, physicians base this diagnosis on the patient’s history and the CDC’s criteria. (See CDC criteria for diagnosing chronic fatigue syndrome.) Because the CDC criteria are admittedly a working concept that may not include all forms of this disease and are based on symptoms that can result from other diseases, diagnosis is difficult and uncertain.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Somatization disorder:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing somatization disorder, page 473.
Diagnostic tests rule out physical disorders that cause vague and confusing symptoms, such as hyperparathyroidism, porphyria, multiple sclerosis, chronic fatigue syndrome, and systemic lupus erythematosus. In addition, multiple physical signs and symptoms that appear for the first time late in life are usually due to physical disease rather than somatization disorder.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Platelet function disorders:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Prolonged bleeding time in a patient with both a normal platelet count and normal clotting factors suggests this diagnosis. Determination of the defective mechanism requires a blood film and a platelet function test to measure platelet release reaction and aggregation. Depending on the type of platelet dysfunction, some or all of the test results may be abnormal.
Other typical laboratory findings are poor clot retraction and decreased prothrombin conversion. Baseline testing includes complete blood count and differential and appropriate tests to determine hemorrhage sites. In platelet function disorders, plasma clotting factors, platelet counts, prothrombin and partial thromboplastin levels, and thrombin times are usually normal.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Fatigue:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are findings associated with psychological disorders.
Ask about related symptoms and any recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and any appetite or weight changes. Carefully review the patient’s medical and psychiatric history for any chronic disorders that commonly produce fatigue, and ask about a family history of such disorders.
Obtain a thorough drug history, noting use of any narcotic or drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk of carbon monoxide poisoning, and ask whether the patient has a carbon monoxide detector.
Observe the patient’s general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Gait, bizarre [Hysterical gait]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you suspect that the patient’s gait impairment has no organic cause, begin to investigate other possibilities. Ask the patient when he first developed the impairment and whether it coincided with any stressful period or event, such as the death of a loved one or loss of a job. Ask about associated symptoms, and explore any reports of frequent unexplained illnesses and multiple physician’s visits. Subtly try to determine if he’ll gain anything from malingering, for instance, added attention or an insurance settlement.
Begin the physical examination by testing the patient’s reflexes and sensorimotor function, noting any abnormal response patterns. To quickly check his reports of leg weakness or paralysis, perform a test for Hoover’s sign: Place the patient in the supine position and stand at his feet. Cradle a heel in each of your palms, and rest your hands on the table. Ask the patient to raise the affected leg. In true motor weakness, the heel of the other leg will press downward; in hysteria, this movement will be absent. As a further check, observe the patient for normal movements when he’s unaware of being watched.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fatigue:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A thorough medical, social, and family history must be conducted to identify comorbid or contributing conditions that require treatment or suggest lifestyle modification.
A. The fatigue should be assessed in terms of duration, onset, level of impairment, and character. Specifically, fatigue should be distinguished from weakness and hypersomnolence.
B. A complete review of systems may point to a cardiovascular, neurologic, psychiatric, infectious, autoimmune, hematologic, pulmonary, endocrine, or malignant cause to pursue.
C. Attention should also be given to medication—both prescription and over-the-counter—and to diet, exercise, substance abuse, and sleep disturbance.
D. Lifestyle issues to explore include caretaking for young children, an elderly or ill relative, and the number of hours worked outside the home. Life stresses or major family transitions such as relocation, death, divorce, financial difficulties and past or current abuse or trauma should also be assessed.
Physical examination
A thorough physical examination should be done to investigate findings of underlying disease. This is also an important prerequisite to satisfy the patient’s concern regarding the possibility of an organic cause if a psychiatric diagnosis is made. Particular attention should be given to the presence of pallor, cardiac arrhythmia, dyspnea, fever or other indication of infection; weight loss; lymphadenopathy; evidence of inflammatory arthritis, occult blood loss, organomegaly, or abdominal masses; neurologic signs of impaired coordination; hypertension; edema; generalized pruritus; obesity; peripheral neuropathy; goiter; dry hair or skin; hemoptysis; or pregnancy. Conduct a mental status examination to identify abnormalities in mood, intellectual function, memory, and personality. Pay special attention to assessment of symptoms of depression or anxiety, suicidal ideation, and psychomotor retardation.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Fatigue:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Infectious mononucleosis
❑ Depression
❑ Diabetes
❑ Hypothyroidism
❑ Drugs
❑ Chronic sleep deprivation
❑ Congestive heart failure
❑ Occult infection
❑ Iron deficiency anemia
❑ Obstructive sleep apnea
❑ Renal failure
❑ Chronic fatigue syndrome
❑ Cushing syndrome
❑ Occult cancer
❑ Addison disease
❑ Myasthenia gravis
Diagnostic Approach
Organic fatigue is characterized by physical weakness or exhaustion, which is exacerbated by activity and partially relieved by sleep, short duration (,2 months), unintentional weight loss of greater than 10%, and an ill appearance. Most organic causes have associated signs and symptoms, specific and few in number.
Psychological fatigue is characterized by a primary inertia to initiation of physical activity, which when undertaken, can be performed. The patient is tired all the time, but fatigue is not exacerbated by exertion or relieved by rest. A protracted course, multiple and nonspecific associated symptoms, relation to stressful life events, and an anxious or depressed appearance are other clues. The sick role response to prior minor illness can indicate likely response to the current illness.
A medical or psychiatric diagnosis can be found in over two-thirds of patients with more than one month of fatigue. Psychiatric diagnoses, especially depression, panic disorder, or somatization disorder are the most common.
A diagnostic approach that involves careful history-taking and physical examination, assiduous avoidance of early closure, and a clear orientation to the reality of the patient’s perceptions whatever the cause (i.e., never implying “It’s all in your head”), is most rewarding. The differential is wide, and identification of the unusual organic causes among the many psychophysiological ones takes great skill.
| Sign | Sensitivity | Specificity | Likelihood Ratio |
| Hypothyroidism |
| Coarse skin | 29 | 95 | 5.6 |
| Cool dry skin | 16 | 97 | 4.7 |
| Periorbital puffiness | 53 | 81 | 2.8 |
| Enlarged thyroid | 46 | 84 | 2.8 |
| Lateral eyebrow hair loss | 29 | 85 | 1.9 |
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Source: Field Guide to Bedside Diagnosis, 2007
Multiple Somatic Complaints:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Anxiety
❑ Depression
❑ Hypothyroidism
❑ Premenstrual syndrome
❑ Hypochondriasis
❑ Somatization disorder
❑ Chronic fatigue syndrome
❑ Fibromyalgia
❑ Panic disorder
❑ Malingering
❑ Conversion reaction
Diagnostic Approach
This presentation is marked by multiple vague complaints, symptoms out of proportion to the physical findings, symptoms outside the anticipated spectrum of the organic disease, and symptoms that do not follow anatomic distributions. The patient is often more concerned with the physician accepting authenticity of symptoms than relieving them. Vague, diffuse descriptions or overly detailed and elaborate symptoms are suggestive. The patient seems to be amplifying normal bodily sensations. Psychological factors may be revealed in the symbolic choice of words (e.g., “lump in the throat”).
“Stress” for most patients is an acceptable framework within which to obtain psychological information. Care must be taken during the interview not to suggest that the symptoms are “all in the head.”
A thorough and thoughtful history and physical examination are the basis for chosing specific diagnostic tests, and signal to the patient that the complaints are being taken seriously.
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Source: Field Guide to Bedside Diagnosis, 2007
Somatization disorder:
Diagnosis
(Handbook of Diseases)
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition – Text Revision details the characteristics of patients with this condition. (See Diagnosing somatization disorder, page 796.)
Diagnostic tests rule out physical disorders that cause vague and confusing symptoms, such as hyperparathyroidism, porphyria, multiple sclerosis, and systemic lupus erythematosus. In addition, multiple physical signs and symptoms that appear for the first time late in life usually stem from physical disease, rather than somatization disorder.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Chronic fatigue and immune dysfunction syndrome:
Diagnosis
(Handbook of Diseases)
The cause and nature of CFIDS are still unknown, and no single test unequivocally confirms its presence. Therefore, the diagnosis is based on the patient’s history and the CDC criteria. Because the CDC criteria are admittedly a working concept that may not include all forms of this disease and are based on symptoms that can result from other diseases, diagnosis is difficult and uncertain. Considerable overlap exists between CFIDS and fibromyalgia syndrome, with many patients having features of both.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Fatigue:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Obtain a careful history to identify the patient’s fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern indicates a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that’s unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.
Ask about related symptoms and any recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and any appetite or weight changes. Carefully review the patient’s medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.
Obtain a thorough drug history, noting use of any opioid or drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient’s risk of carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Fatigue:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Physiologic Causes
Children who lack sleep and rest, have decreasedcaloric intake, and engage in strenuous or prolonged exercise arelikely to experience fatigue.
Pathologic Causes
Anemia
Any typeof anemia can produce fatigue.Pallor is usually evident with moderate-to-severeanemia.CBC should be performed as screeningtest. Infection
Any acute or chronic infection can producefatigue. Common infections that are often associated with prolongedor severe fatigue include infectious mononucleosis, influenza, hepatitisA, tuberculosis, and endocarditis.
Chronic Disease
Fatigue often occurs with cardiac disease(cardiac failure, cyanotic congenital heart disease, pulmonary vasculardisease), pulmonary disease (asthma, cystic fibrosis), chronic renaldisease, inflammatory bowel disease, chronic liver disease, collagenvascular disease, endocrine disorders (hypothyroidism, hyperthyroidism,adrenal insufficiency), muscle disorders that cause weakness, malnutrition,and malignancy.
Allergic Disease
Children with allergic rhinitis (seasonalor perennial) or asthma often experience fatigue, until their symptomsare relieved.
Chronic Fatigue Syndrome
Revisedcase definition of this syndrome was proposed by Fukada et al. (1994).Characterized by unexplained persistentor relapsing fatigue for >6 mos that seriously interfereswith normal activities. Not related to ongoing exertion nor is itsubstantially relieved by rest.≥4 of the following symptoms musthave persisted or recurred during 6-mo period and must not havepredated fatigue: sore throat; tender cervical or axillary adenopathy;muscle pain; pain in multiple joints without swelling or redness;headaches of new type, pattern, or severity; awakening from sleepstill tired; malaise lasting >24 hrs after exertion; andimpaired short-term memory or concentration.Diagnosis is clinical. Drugs
Fatigue is common side effect of many drugs,including antihistamines, anticonvulsants, tranquilizers, and opiates.
Psychologic
Psychologicdisturbances (e.g., anxiety, depression, grief reaction, schoolphobia, or somatization disorder) can cause fatigue.History and clinical observation areusually diagnostic. Diagnostic Approach
When childcomplains of fatigue, history and physical exam are often diagnostic.CBC can screen for anemia.Monospot test can confirm diagnosisof infectious mononucleosis, but if result is negative, Epstein-Barrvirus IgG and IgM antibodies can be performed.Psychosocial history is most importantdiagnostic tool for psychologic problems.If diagnosis remains uncertain, initialscreening investigations for chronic disease include sedimentationrate; stool guaiac; serum electrolytes, glucose, creatinine, aminotransferases;blood urea nitrogen; UA; chest radiography; and intermediate-strengthtuberculin skin test.Other investigations depend on suspecteddiagnosis and results of these tests.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Fatigue:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Obtain a careful history to identify the patient's fatigue pattern. Fatigue that worsens with activity and improves with rest generally indicates a physical disorder; the opposite pattern, a psychological disorder. Fatigue lasting longer than 4 months, constant fatigue that's unrelieved by rest, and transient exhaustion that quickly gives way to bursts of energy are other findings associated with psychological disorders.
Ask about related symptoms and recent viral or bacterial illness or stressful changes in lifestyle. Explore nutritional habits and appetite or weight changes. Carefully review the patient's medical and psychiatric history for chronic disorders that commonly produce fatigue. Ask about a family history of such disorders.
Obtain a thorough drug history, noting the use of any drug with fatigue as an adverse effect. Ask about alcohol and drug use patterns. Determine the patient's risk of carbon monoxide poisoning, and inquire as to whether the patient has a carbon monoxide detector in the home.
Observe the patient's general appearance for overt signs of depression or organic illness. Is he unkempt or expressionless? Does he appear tired or sickly, or have a slumped posture? If warranted, evaluate his mental status, noting especially mental clouding, attention deficits, agitation, or psychomotor retardation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Gait, bizarre [Hysterical gait]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you suspect that the patient's gait impairment has no organic cause, begin to investigate other possibilities. Ask the patient when he first developed the impairment and whether it coincided with a stressful period or event, such as the death of a loved one or loss of a job. Ask about associated symptoms, and explore reports of frequent unexplained illnesses and multiple physician's visits. Subtly try to determine if the patient will gain anything from malingering, for instance, added attention or an insurance settlement.
Begin the physical examination by testing the patient's reflexes and sensorimotor function, noting abnormal response patterns. To quickly check his reports of leg weakness or paralysis, perform a test for Hoover's sign: Place the patient in the supine position and stand at his feet. Cradle a heel in each of your palms, and rest your hands on the table. Ask the patient to raise the affected leg. In true motor weakness, the heel of the other leg will press downward; in hysteria, this movement will be absent. As a further check, observe the patient for normal movements when he's unaware of being watched.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
WEAKNESS AND FATIGUE, GENERALIZED:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs with generalized weakness
and fatigue is very important in pinning down a diagnosis. Generalized
lymphadenopathy and fatigue suggest infectious mononucleosis, lymphoma, or
tuberculosis or other chronic infection such as acquired immunodeficiency
syndrome (AIDS). Weakness, weight loss, and polyphagia with polyuria and
polydipsia would suggest hyperthyroidism or diabetes mellitus. Generalized
weakness with polyuria and no significant weight loss suggests
hyperparathyroidism. Weakness with pallor suggests some type of anemia.
Weakness and weight loss without polyuria or polyphagia suggest malignancy
or malabsorption syndrome. Weakness with other significant neurologic signs
and symptoms prompts the consideration of muscular dystrophy, amyotrophic
lateral sclerosis, or multiple sclerosis. Weakness with drug or alcohol use
prompts the investigation of drug or alcohol abuse. Caffeine, especially in
large quantities, can also cause significant weakness and chronic fatigue.
The initial workup of weakness and fatigue requires a CBC, sedimentation
rate, drug screen, chemistry panel, thyroid profile, ANA, chest x-ray, and
echocardiogram (ECG). If muscular dystrophy or dermatomyositis is suspected,
urine tests for creatinine, creatine, and myoglobin can be done. Ultimately,
a muscle biopsy may be indicated. If myasthenia gravis is suspected, serum
for acetylcholine receptor antibody may be done. If Addison disease is
suspected, a serum cortisol test may be done. A 24-hour urine aldosterone
level may be done to exclude primary aldosteronism. Serum parathyroid
hormone (PTH) may be done to exclude hyperparathyroidism.
It would be wise to consult an infectious disease specialist before ordering
an expensive workup. It would also be wise to consult an oncologist when
searching for a malignancy before ordering an expensive workup.
When all tests have negative findings, many clinicians have been tempted to
make a diagnosis of chronic fatigue syndrome. It is questionable whether
this is truly a disease or not.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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