1. Physical Examination of Chronic Fatigue Syndrome Bali Mental Hospital Shin-Min Lee May, 2005

2. Chronic fatigue syndrome (CFS) A debilitating and complex disorder characterized by profound fatigue that is not improved by bed rest and that may be worsened by physical or mental activity. Persons with CFS most often function at a substantially lower level of activity than they were capable of before the onset of illness.

3. Chronic fatigue syndrome (CFS) In addition to these key defining characteristics, patients report various nonspecific symptoms, including weakness, muscle pain, impaired memory and/or mental concentration, insomnia, and post-exertional fatigue lasting more than 24 hours. In some cases, CFS can persist for years.

4. Chronic fatigue syndrome (CFS) The cause or causes of CFS have not been identified and no specific diagnostic tests are available. Moreover, since many illnesses have incapacitating fatigue as a symptom, care must be taken to exclude other known and often treatable conditions before a diagnosis of CFS is made.

5. CFS : Two Criteria (1) 1). Have severe chronic fatigue of six months or longer duration with other known medical conditions excluded by clinical diagnosis;

6. CFS : Two Criteria (2) 2). Concurrently have four or more of the following symptoms: –substantial impairment in short-term memory or concentration; –sore throat; –tender lymph nodes; –muscle pain; –multi-joint pain without swelling or redness; –headaches of a new type, pattern or severity; – unrefreshing sleep; –post-exertional malaise lasting more than 24 hours.

7. CFS : Criteria The symptoms must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue.

8. Similar Medical Conditions A number of illnesses have been described that have a similar spectrum of symptoms to CFS –fibromyalgia syndrome, –myalgic encephalomyelitis, –neurasthenia, –multiple chemical sensitivities, and –chronic mononucleosis Although these illnesses may present with a primary symptom other than fatigue, chronic fatigue is commonly associated with all of them.

9. Other Conditions That May Cause Similar Symptoms (1) In addition, there are a large number of clinically defined, frequently treatable illnesses that can result in fatigue. Diagnosis of any of these conditions would exclude a definition of CFS unless the condition has been treated sufficiently and no longer explains the fatigue and other symptoms.

10. Other Conditions That May Cause Similar Symptoms (2) These include : –hypothyroidism, –sleep apnea and narcolepsy, –major depressive disorders, –chronic mononucleosis, –bipolar affective disorders, –schizophrenia,

11. Other Conditions That May Cause Similar Symptoms (3) These include : –eating disorders, –cancer, –autoimmune disease, –hormonal disorders*, –subacute infections, –obesity, –alcohol or substance abuse, –and reactions to prescribed medications.

12. Other Commonly Observed Symptoms in CFS (1) In addition to the eight primary defining symptoms of CFS, a number of other symptoms have been reported by some CFS patients. The frequencies of occurrence of these symptoms vary from 20% to 50% among CFS patients.

13. Other Commonly Observed Symptoms in CFS (2) They include abdominal pain, alcohol intolerance, bloating, chest pain, chronic cough, diarrhea, dizziness, dry eyes or mouth, earaches, irregular heartbeat, jaw pain, morning stiffness, nausea, night sweats, psychological problems (depression, irritability, anxiety, panic attacks), shortness of breath, skin sensations, tingling sensations, and weight loss.

14. How Common Is CFS? (1) Between 4.0 and 8.7 per 100,000 persons 18 years of age or older have CFS and are under medical care. (Centers for Disease Control and Prevention, CDC; from 1989 to 1993) Seattle area has estimated that CFS affects between 75 and 265 people per 100,000 population.

15. How Common Is CFS ? (2) San Francisco, at approximately 200 per 100,000 persons. In general, it is estimated that perhaps as many as half a million persons in the United States have a CFS-like condition.

16. Who Gets CFS? (1) This question is complex and does not have a definitive answer. The CDC four-city surveillance study of CFS identified a population of patients that was 98% Caucasian and 85% female, with an average age at onset of 30 years. More than 80% had advanced education and one-third were from upper income families. However, these data included only patients who were under a physician's care.

17. Who Gets CFS? (2) There is now evidence that CFS affects all racial and ethnic groups and both sexes. The Seattle study found that 59% of the CFS patients were women. Eighty-three percent were Caucasian, an underrepresentation, since over 90% of the patients in the study were white. CDC's San Francisco study found that CFS-like disease was most prevalent among women, among persons with household annual incomes of under $40,000, and among blacks, and was least common among Asians and whites.

18. Who Gets CFS? (3) Adolescents can have CFS, but few studies of adolescents have been published. Adolescents 12 to 18 years of age had CFS significantly less frequently than adults and did not identify CFS in children under 12 years of age. CFS-like illness has been reported in children under 12 by some investigators, although the symptom pattern varies somewhat from that seen in adults and adolescents. The illness in adolescents has many of the same characteristics as it has in adults.

19. Who Gets CFS? (4) However, it is particularly important that the unique problems of chronically ill adolescents (e.g., family social and health interactions, education, social interactions with peers) be considered as a part of their care. Appropriate dissemination of CFS information to patients, their families, and school authorities is also important. CDC and the National Institutes of Health (NIH) are currently pursuing studies of CFS in children and adolescents.

20. Clinical Course of CFS (1) The clinical course of CFS varies considerably among persons who have the disorder; the actual percentage of patients who recover is unknown, and even the definition of what should be considered recovery is subject to debate. Some patients recover to the point that they can resume work and other activities, but continue to experience various or periodic CFS symptoms. Some patients recover completely with time, and some grow progressively worse.

21. Clinical Course of CFS (2) CFS often follows a cyclical course, alternating between periods of illness and relative well being. CDC continues to monitor the patients enrolled in the four-city surveillance study; recovery is defined by the patient and may not reflect complete symptom-free recovery. Approximately 50% of patients reported "recovery," and most recovered within the first 5 years after onset of illness.

22. Clinical Course of CFS (3) No characteristics were identified that made one patient more likely to recover than another. At illness onset, the most commonly reported CFS symptoms were sore throat, fever, muscle pain, and muscle weakness. As the illness progressed, muscle pain and forgetfulness increased and the reporting of depression decreased.

23. Possible Causes of CFS A. Infectious Agents B. Immunology C. Hypothalamic-Pituitary Adrenal Axis D. Neurally Mediated Hypotension F. Nutritional Deficiency

24. Treatment of Patients with CFS A variety of therapeutic approaches have been described as benefiting patients with chronic fatigue syndrome (CFS) No cause for CFS has been identified and the pathophysiology remains unknown Treatment programs are directed at relief of symptoms, with the goal of the patient regaining some level of pre-existing function and well-being.

25. Treatment of Patients with CFS Non-Pharmacologic Therapy –Physical Activity Education Pharmacologic Therapy Prescription Medication Experimental Drugs and Treatments Dietary Supplements and Herbal Preparations

26. A Brief Explanation of How CFS Patients are Evaluated by a Physician