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Toronto Notes 2019 Common Presenting Problems
Treatment
• treatunderlyingcause
• ifetiologycannotbeidentified(1/3ofpatients)
■ reassurance and follow-up, especially with fatigue of psychogenic etiology
■ supportive counselling, behavioural, or group therapy
■ encourage patient to stay physically active to maximize function
■ review all medications, OTC, and herbal remedies for drug-drug interactions and side effects ■ prognosis: after 1 yr, 40% are no longer fatigued
CHRONIC FATIGUE SYNDROME
Definition (CDC 2006) – must meet both criteria
1. new or definite onset of unexplained, clinically evaluated, persistent or relapsing chronic fatigue, not
relieved by rest, which results in occupational, educational, social, or personal dysfunction 2. concurrent presence of ≥4 of the following symptoms for a minimum of 6 mo
■ impairment of short-term memory or concentration, severe enough to cause significant decline in function
■ sore throat
■ tender cervical or axillary lymph nodes
■ muscle pain
■ multi-joint pain with no swelling or redness
■ new headache
■ unrefreshing sleep
■ post-exertion malaise lasting >24 h
• exclusioncriteria:medicalconditionsthatmayexplainthefatigue,certainpsychiatricdisorders (depression with psychotic or melancholic features, schizophrenia, eating disorders), substance abuse, severe obesity (BMI >45)
Epidemiology
• F>M,Caucasians>othergroups,majorityintheir30s • foundin<5%ofpatientspresentingwithfatigue
Etiology
• unknown,likelymultifactorial
• mayincludeinfectiousagents,immunologicalfactors,neurohormonalfactors,and/ornutritional
deficiency
Investigations
• nospecificdiagnosticlaboratorytests
Treatment
• promotesleephygiene
• providesupportandreassurancethatmostpatientsimproveovertime • non-pharmacological
■ regular physical activity, optimal diet, psychotherapy (e.g. CBT), family therapy, support groups • pharmacological
■ to relieve symptoms: e.g. antidepressants, anxiolytics, NSAIDs, antimicrobials, antiallergy therapy, antihypotensive therapy
Family Medicine FM31
Fever
• seePediatrics,P47
Definition
• oraltemperature>37.2°C(AM),37.7°C(PM)
• feverinchildrenunder2mustbearectaltemperatureforaccuracy • TMnotaccurateformeasurementuntilchildis>5yr
Exercise Therapy for Chronic Fatigue
Cochrane Database Syst Rev 2017;4:CD003200 Purpose: To determine the effectiveness of exercise therapy for chronic fatigue syndrome (CFS). Methods: Meta-analysis of RCTs involving adults with CFS as a primary diagnosis who were
able to participate in exercise therapy. Studies compared exercise therapy to passive control, psychological therapies, adaptive pacing therapy or pharmacological therapy.
Results: 8 RCTs with 1,518 participants were included. Exercise therapy lasted 12 to 26 wk
in duration. Moderate-quality evidence showed exercise therapy was more effective in reducing fatigue relative to passive or no treatment, and was also associated with a positive effect on daily physical functioning, sleep and self-rated overall health. One study suggested exercise therapy was more effective than pacing strategies for fatigue reduction, though was no more effective than cognitive behavioural therapy (CBT). Exercise therapy was not found to worsen symptoms for CFS patients, and serious side-effects were rare across all intervention groups.
Conclusion: Exercise therapy may be beneficial
to overall health and may decrease fatigue in CFS patients, and is not associated with worsening outcomes. Therapy may also have a positive impact on sleep, physical function, and self-perceived general health. In general, exercise therapy appears more effective than pacing strategies, and similar to CBT.
Table 19. Differential Diagnosis of Fever
Infection
Bacterial Viral
TB
Cancer
Leukemia Lymphoma
Other Malignancies
Medications
Allopurinol Captopril Cimetidine Heparin INH Meperidine
Nifidepine Phenytoin Diuretics Barbiturates Antihistamines
Other
Irritable Bowel Syndrome Collagen Vascular Disease DVT