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

2. A.Fardmousavi Fatigue may be divided into three categories based upon the duration of symptoms: 1- Recent fatigue refers to symptoms lasting less than one month 2- Prolonged fatigue refers to symptoms lasting for more than one month 3- Chronic fatigue refers to symptoms lasting over six months, but does not necessarily imply the presence of the chronic fatigue syndrome 1- Recent fatigue refers to symptoms lasting less than one month 2- Prolonged fatigue refers to symptoms lasting for more than one month 3- Chronic fatigue refers to symptoms lasting over six months, but does not necessarily imply the presence of the chronic fatigue syndrome

3. A.Fardmousavi

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

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

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

8. A.Fardmousavi The clinician should rely upon open- ended questions, encouraging the patient to describe the fatigue in his or her own words. Questions and comments such as "What do you mean by fatigue?" or "Please describe what you mean" may elicit responses which suggest a generalized sense of tiredness that help distinguish fatigue from dyspnea, somnolence, and true weakness.

9. A.Fardmousavi Patients with organ-based medical illness often associate their fatigue with activities they are unable to complete. In contrast, patients with fatigue that is not organ-based are tired all the time; their fatigue is not necessarily related to exertion, nor does it improve with rest.

10. A.Fardmousavi The impact and duration of fatigue should be assessed to determine whether further history and evaluation should focus upon the fatigue itself, or whether the fatigue should simply be noted but not explored directly (at least not at the first visit).

11. A.Fardmousavi Fatigue of recent onset may be short- lived, while fatigue that lasts six months may represent a chronic and potentially debilitating illness. The clinician should determine the extent to which the patient's fatigue interferes with work, family, or activities of daily living, and what changes in lifestyle the patient has made in response to his or her fatigue.

12. A.Fardmousavi The history should include questions screening for psychiatric disorders (particularly depression, anxiety disorders, somatization disorders, and substance abuse) early in the evaluation of the fatigued patient in view of the strong relationship between chronic fatigue and psychiatric illness described above

13. A.Fardmousavi There is a general perception among practitioners that patients who complain of chronic fatigue are reluctant to accept a psychologic explanation for their symptoms. However, up to two- thirds of patients with fatigue, when asked, will acknowledge a psychosocial contribution to this symptom

14. A.Fardmousavi The quantity and quality of the patient's sleep should be assessed to determine whether or not sleep improves the patient's symptoms. Such improvement may suggest a primary sleep disorder or disturbed sleep as an etiology for the patient's fatigue.

15. A.Fardmousavi A thorough evaluation of medications, both prescribed and over the counter, should be undertaken. Recreational drug use, including alcohol, should be carefully explored in any patient with fatigue.

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

17. A.Fardmousavi The general appearance of the patient should be considered for possible signs of a psychiatric disorder such as a diminished level of alertness, psychomotor agitation or retardation, and poor grooming. The general appearance of the patient should be considered for possible signs of a psychiatric disorder such as a diminished level of alertness, psychomotor agitation or retardation, and poor grooming.

18. A.Fardmousavi A thorough evaluation for lymphadenopathy, a possible sign of chronic infection or malignancy, should be performed. A thorough evaluation for lymphadenopathy, a possible sign of chronic infection or malignancy, should be performed.

19. A.Fardmousavi Pallor, tachycardia, and a systolic ejection murmur may suggest anemia. Pallor, tachycardia, and a systolic ejection murmur may suggest anemia.

20. A.Fardmousavi Evidence of thyroid disease should be sought, including a goiter or thyroid nodule, ophthalmologic changes, and delayed deep tendon reflexes. Evidence of thyroid disease should be sought, including a goiter or thyroid nodule, ophthalmologic changes, and delayed deep tendon reflexes.

21. A.Fardmousavi The cardiopulmonary examination should focus upon detecting signs of congestive heart failure and chronic lung disease, both important causes of fatigue. The cardiopulmonary examination should focus upon detecting signs of congestive heart failure and chronic lung disease, both important causes of fatigue.

22. A.Fardmousavi A complete neurologic examination is warranted, including assessment of muscle bulk, tone and strength, abnormalities which would suggest a neuromuscular disorder to account for the patient's fatigue. A complete neurologic examination is warranted, including assessment of muscle bulk, tone and strength, abnormalities which would suggest a neuromuscular disorder to account for the patient's fatigue.

23. A.Fardmousavi Laboratory studies Laboratory evaluations in the absence of a positive history or physical examination are of little diagnostic utility in the evaluation of the fatigued patient Laboratory evaluations in the absence of a positive history or physical examination are of little diagnostic utility in the evaluation of the fatigued patient

24. A.Fardmousavi 1-complete blood count with differential 2-erythrocyte sedimentation rate 3-chemistry screen including liver function tests and measurement of serum creatine kinase, calcium, and thyroid stimulating hormone (TSH). 4-HIV testing 5-PPD placement

25. A.Fardmousavi In menstruating women, it may be appropriate to check iron studies even in the absence of anemia since treatment with iron has been found to help some women with a normal hemoglobin but low serum ferritin

26. A.Fardmousavi Screening examinations appropriate for the age and sex of the patient, such as mammography and sigmoidoscopy, should be performed at some point during the evaluation.

27. A.Fardmousavi weakness The evaluation of the patient presenting with a complaint of "weakness" involves three steps The evaluation of the patient presenting with a complaint of "weakness" involves three steps 1-Distinguishing true muscle weakness from functional motor impairment not due to loss of muscle power 2- Localizing the site of the lesion within the neuromuscular system that is producing weakness 3- Determining the cause of the lesion 1-Distinguishing true muscle weakness from functional motor impairment not due to loss of muscle power 2- Localizing the site of the lesion within the neuromuscular system that is producing weakness 3- Determining the cause of the lesion

28. A.Fardmousavi DISTINGUISHING TRUE MUSCLE WEAKNESS FROM FUNCTIONAL WEAKNESS Many patients who complain of weakness are not objectively weak when muscle strength is formally tested. A careful history and physical examination will permit the distinction between functional disease and true weakness. Many patients who complain of weakness are not objectively weak when muscle strength is formally tested. A careful history and physical examination will permit the distinction between functional disease and true weakness.

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

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

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

32. A.Fardmousavi Muscle strength is preserved in patients with cachexia despite advanced generalized muscle atrophy. In contrast, patients with true muscle weakness due to a myopathy generally have normal muscle bulk at the time of presentation. Muscle strength is preserved in patients with cachexia despite advanced generalized muscle atrophy. In contrast, patients with true muscle weakness due to a myopathy generally have normal muscle bulk at the time of presentation.

33. A.Fardmousavi Muscle tenderness is usually not associated with one of the causes of true muscle weakness. There are, however, exceptions to this general rule including infectious myopathies such as trichinosis and viral myositis, certain drug-induced myopathies, thyroid myopathy, and the inherited metabolic myopathies. Muscle tenderness is usually not associated with one of the causes of true muscle weakness. There are, however, exceptions to this general rule including infectious myopathies such as trichinosis and viral myositis, certain drug-induced myopathies, thyroid myopathy, and the inherited metabolic myopathies.

34. A.Fardmousavi True muscle weakness is documented by formal muscle testing. The strength of each muscle can be assessed by determining how much force is required by the examiner to overcome maximal contraction by the patient. A widely used system to measure muscle strength is the grading system from the Medical Research Council which is based upon a scale of zero to five

35. A.Fardmousavi Zero — no contraction One — flicker or trace of contraction Two — muscle contraction possible only with gravity eliminated Three — muscle contraction against gravity only Four — power decreased but muscle contraction possible against resistance Five — normal power resistance Zero — no contraction One — flicker or trace of contraction Two — muscle contraction possible only with gravity eliminated Three — muscle contraction against gravity only Four — power decreased but muscle contraction possible against resistance Five — normal power resistance