Chronic Fatigue Syndrome
Doctor Information
Carol Heath Aged 29
Past Medical History: None
Allergies: Nill
Past consultation: Seen one week ago by Dr Fernandez (locum)
Patient complaining of a 4 month history of fatigue and lethargy. Family history of thyroid disease, wondering if this could be the cause?? Denies any excessive blood loss, no urinary frequency . increased thirst. No constipation / diarrhoea. Examination: unremarkable. Plan: to arrange blood test, then review.
Blood Test Result: (All Normal)
Hb: 11.8
Ferritin: 150
Hba1c: 32
TSH: 2.1
Adjusted Calcium: 2.25
eGFR: >90
Sodium:140
Potassium: 5.1
LFT’s: Normal.
Coeliacs screen: negative
Vitamin D: Normal.
Past Medical History: None
Allergies: Nill
Past consultation: Seen one week ago by Dr Fernandez (locum)
Patient complaining of a 4 month history of fatigue and lethargy. Family history of thyroid disease, wondering if this could be the cause?? Denies any excessive blood loss, no urinary frequency . increased thirst. No constipation / diarrhoea. Examination: unremarkable. Plan: to arrange blood test, then review.
Blood Test Result: (All Normal)
Hb: 11.8
Ferritin: 150
Hba1c: 32
TSH: 2.1
Adjusted Calcium: 2.25
eGFR: >90
Sodium:140
Potassium: 5.1
LFT’s: Normal.
Coeliacs screen: negative
Vitamin D: Normal.
Patient Information
Carol Heath Aged 29
Opening sentence: You have come back to see the GP to go through your blood results
Your history: (you will reveal readily)
Around 4 months ago you started to feel very tired, you felt that as soon as you did anything you became exhausted very quickly. After any exertion it would take you longer and longer to recover, and eventually you might be ‘out’ for days after doing something particularly strenuous. This has resulted in you doing less and less exercise.
Over the last few weeks you’ve also found yourself aching all over. you’ve found your muscles particularly achey at times. You've also had difficulty sleeping, finding it difficult to get to sleep, and then after your sleep, you find yourself feeling very un-refreshed.
You have no symptoms suggestive of anaemia (not pale, not short of breath on exertion, not tired during exercise - just afterwards), thyroid disease (no constipation, no change in your periods, no tremor, myxoedema, not feeling cold, no weight gain), diabetes (no increased thirst / urination / weight loss), sleep apnoea (no snoring, no pausing / apnoeas overnight). Your mood is positive, you do not feel down, depressed nor hopeless, and look forward to doing many things currently.
You have no symptoms nor signs of cancer - no abnormal bleeding, no lumps / bumps.
Social history:
You’re a non smoker, you drink around 1-2 glasses of wine per week. You work as a teaching assistant in a local school, but are struggling to make it in at the moment. You work full time, but are finding it harder and harder to cope! You live at home with your boyfriend of 5 years. You find little time for exercise, and eat what ever you can - usually quick meals / microwave meals / frozen meals.
Psychosocial impact:
you are finding life difficult to cope with, especially work. The problems you have is that due to economic pressures, your employment would be in jeopardy if you took too much time off, so you really want there to be a solution for this, a simple tablet that will help
Medical History:
You have asthma that’s very well controlled.
Drug History:
You take Salbutamol on a PRN basis, and Clenil 100mcg - two puffs BD.
Ideas:
You hope that this is a thyroid issue, as you have done some googling, and know that there is a quick and easy solution.
Concerns:
Your greatest fear is that there is no quick fix, and that this is something that will linger for a long time, as you cant afford to have time off work, as you are reliant on it for your financial stability.
Expectations:
You really want this to be a quick solution, and even if the thyroid tests are normal, and the iron levels are normal, you will push to try iron or thyroid tablets any way - just in case they do improve things - you will push for this.
How to respond:
You will be upset if no easy fix is found, and you will push really hard to try the iron or thyroxine tablets, you don't mind if its only a quick one month trial just to see, and you don't mind any follow up the GP will offer. If the GP is insistent that this will not work as your bloods are normal, and they are nice and offer you a referral to get help - you will agree to this.
Opening sentence: You have come back to see the GP to go through your blood results
Your history: (you will reveal readily)
Around 4 months ago you started to feel very tired, you felt that as soon as you did anything you became exhausted very quickly. After any exertion it would take you longer and longer to recover, and eventually you might be ‘out’ for days after doing something particularly strenuous. This has resulted in you doing less and less exercise.
Over the last few weeks you’ve also found yourself aching all over. you’ve found your muscles particularly achey at times. You've also had difficulty sleeping, finding it difficult to get to sleep, and then after your sleep, you find yourself feeling very un-refreshed.
You have no symptoms suggestive of anaemia (not pale, not short of breath on exertion, not tired during exercise - just afterwards), thyroid disease (no constipation, no change in your periods, no tremor, myxoedema, not feeling cold, no weight gain), diabetes (no increased thirst / urination / weight loss), sleep apnoea (no snoring, no pausing / apnoeas overnight). Your mood is positive, you do not feel down, depressed nor hopeless, and look forward to doing many things currently.
You have no symptoms nor signs of cancer - no abnormal bleeding, no lumps / bumps.
Social history:
You’re a non smoker, you drink around 1-2 glasses of wine per week. You work as a teaching assistant in a local school, but are struggling to make it in at the moment. You work full time, but are finding it harder and harder to cope! You live at home with your boyfriend of 5 years. You find little time for exercise, and eat what ever you can - usually quick meals / microwave meals / frozen meals.
Psychosocial impact:
you are finding life difficult to cope with, especially work. The problems you have is that due to economic pressures, your employment would be in jeopardy if you took too much time off, so you really want there to be a solution for this, a simple tablet that will help
Medical History:
You have asthma that’s very well controlled.
Drug History:
You take Salbutamol on a PRN basis, and Clenil 100mcg - two puffs BD.
Ideas:
You hope that this is a thyroid issue, as you have done some googling, and know that there is a quick and easy solution.
Concerns:
Your greatest fear is that there is no quick fix, and that this is something that will linger for a long time, as you cant afford to have time off work, as you are reliant on it for your financial stability.
Expectations:
You really want this to be a quick solution, and even if the thyroid tests are normal, and the iron levels are normal, you will push to try iron or thyroid tablets any way - just in case they do improve things - you will push for this.
How to respond:
You will be upset if no easy fix is found, and you will push really hard to try the iron or thyroxine tablets, you don't mind if its only a quick one month trial just to see, and you don't mind any follow up the GP will offer. If the GP is insistent that this will not work as your bloods are normal, and they are nice and offer you a referral to get help - you will agree to this.
Examination Findings
Examination
Looks well, good colour.
conjuctiva: good colour
Pulse: 64
BP: 126/80
BMI: 27
Neck Examination: no thyroid mass. No tremor, No thyroid acropachy, no myxoedema, No thyroid eye disease. No lymphadenopathy
Looks well, good colour.
conjuctiva: good colour
Pulse: 64
BP: 126/80
BMI: 27
Neck Examination: no thyroid mass. No tremor, No thyroid acropachy, no myxoedema, No thyroid eye disease. No lymphadenopathy
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Clarifies the problem & nature of decision required Uses an incremental approach, using time and accepting uncertainty Gathers information from history taking, examination and investigation in a systematic and efficient manner. Is appropriately selective in the choice of enquiries, examinations & investigations |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify normal data |
Clinical Management Skills
|
POSITIVE INDICATORS
Recognises presentations of chronic fatigue syndrome Offers appropriate and feasible management options Management approaches reflect an appropriate assessment of risk Doesn't offer any prescriptions Refers appropriately & co-ordinates care with other healthcare professionals Safety netting appropriately Encourages improvement, rehabilitation, and, where appropriate, recovery. |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Prescribes inappropriately (T4 or iron) Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies. |
Inter Personal Skills
|
POSITIVE INDICATORS
Explores patient’s agenda, health beliefs & preferences. Appears alert to verbal and non-verbal cues. Explores the impact of the illness on the patient's life Elicits psychological & social information to place the patient’s problem in context Works in partnership, finding common ground to develop a shared management plan Shows responsiveness to the patient's preferences, feelings and expectations Provides explanations that are relevant and understandable to the patient Responds to needs & concerns with interest & understanding Does not allow own views/values to inappropriately influence dialogue Is cooperative & inclusive in approach |
NEGATIVE INDICATORS
Does not inquire sufficiently about the patient’s perspective / health understanding. Pays insufficient attention to the patient's verbal and nonverbal communication. Fails to explore how the patient's life is affected by the problem. Does not appreciate the impact of the patient's psychosocial context Instructs the patient rather than seeking common ground Uses a rigid approach to consulting that fails to be sufficiently responsive to the patient's contribution Fails to empower the patient or encourage self-sufficiency Uses inappropriate (e.g. technical) language Shows little visible interest/understanding, lacks warmth in voice/manner Does not show sufficient respect for others. Inappropriately influences patient interaction through own views/values Is quick to judge Appears patronising or inappropriately paternalistic |
Management
Chronic Fatigue Syndrome
This case focuses around the diagnosis and management of likely chronic fatigue syndrome, it also covers the very common presentation of ‘Tired all the time’
NICE CKS do have a very detailed discussion around the diagnosis and management of Chronic Fatigue Syndrome (otherwise known as Myalgic Encephalomyelitis) - Link here: http://cks.nice.org.uk/tirednessfatigue-in-adults#!diagnosissub:2
Diagnosis:
Based on the current NICE guidelines around the diagnosis of Chronic Fatigue Syndrome:
http://www.nice.org.uk/guidance/CG53
This case focuses around the diagnosis and management of likely chronic fatigue syndrome, it also covers the very common presentation of ‘Tired all the time’
NICE CKS do have a very detailed discussion around the diagnosis and management of Chronic Fatigue Syndrome (otherwise known as Myalgic Encephalomyelitis) - Link here: http://cks.nice.org.uk/tirednessfatigue-in-adults#!diagnosissub:2
Diagnosis:
Based on the current NICE guidelines around the diagnosis of Chronic Fatigue Syndrome:
http://www.nice.org.uk/guidance/CG53
In adults, suspect chronic fatigue syndrome (CFS)/myalgic encephalomyelitis or encephalopathy (ME) if both of the following criteria are met:
The person has fatigue that has all of the following features:
Persistent (for 4 months or longer) or recurrent.
Unexplained by other conditions
Has resulted in a substantial reduction in activity level.
Characterized by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days).
The person has one or more of the following symptoms:
Difficulty with sleeping (such as insomnia, hypersomnia, unrefreshing sleep, or a disturbed sleep-wake cycle).
Muscle or joint pain that is multi-site and without evidence of inflammation.
Headaches.
Painful lymph nodes without pathological enlargement.
Sore throat.
Cognitive dysfunction (such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organising thoughts, and information processing).
Physical or mental exertion makes symptoms worse.
General malaise or flu-like symptoms.
Dizziness or nausea.
Palpitations in the absence of identified cardiac pathology.
The diagnosis of CFS/ME should be reconsidered if none of the following features are present:
Post-exertional fatigue or malaise.
Cognitive difficulties.
Sleep disturbance.
Chronic pain.
Red Flags for assessment:
It is important to recognise that tiredness in adults could be a symptom of something more serious, such as cancer, so remember to enquire about / examine for any:
It is important to recognise that tiredness in adults could be a symptom of something more serious, such as cancer, so remember to enquire about / examine for any:
Significant weight loss
Lymphadenopathy suggestive of malignancy
Haemoptysis
Dysphagia
Rectal bleeding
Breast lump
Postmenopausal bleeding
Localising neurological signs- brain tumour, MS,
Symptoms and signs of inflammatory arthritis, vasculitis or connective tissue disease or Rheumatoid arthritis.
Symptoms and signs of cardiorespiratory disease - COPD / Heart failure.
Sleep apnoea
Carbon monoxide poisoning
Explanation:
Your blood results have come back reassuringly normal, but this can be frustrating as it does not give us an easy answer to explain why you are feeling the way you are. One diagnosis that may be worth exploring is called chronic fatigue syndrome - sometimes called M.E. Is this something that you’ve heard of?
The main symptoms of CFS is fatigue to an overwhelming extent - usually stopping them from doing what they would usually do. It can also be associated with other problems, such as headaches, muscle aches, sleep disturbance as well as problems with concentration and memory. Unfortunately there is no test we can do that confirms the diagnosis, and it is often a diagnosis made if we can’t find any other cause.
There are things that can be done to help the symptoms, and most people will improve over time. We generally recommend a referral to a chronic fatigue clinic, as they have access to specialist physiotherapists / psychotherapists, who can help you along the road to recovery.
Management
Refer adults with symptoms suggestive of chronic fatigue syndrome/myalgic encephalomyelitis to specialist CFS/ME services:
Consider referring to secondary care those people with persistent, unexplained tiredness/fatigue not meeting the criteria for CFS/ME if any of the following apply:
There is significant uncertainty regarding the underlying cause, the patient would benefit from the reassurance of a second opinion or the patient may benefit from access to the multidisciplinary care delivered by specialist CFS/ME services.
Children and young people 17 years of age or younger should be referred to paediatrics within 6 weeks of presentation.
Treatment Strategies:
For people meeting criteria for CFS/ME who have not yet been assessed by specialist CFS/ME services:
NICE is currently working on an updated version of its CFS / ME guidelines, due out soon.
Your blood results have come back reassuringly normal, but this can be frustrating as it does not give us an easy answer to explain why you are feeling the way you are. One diagnosis that may be worth exploring is called chronic fatigue syndrome - sometimes called M.E. Is this something that you’ve heard of?
The main symptoms of CFS is fatigue to an overwhelming extent - usually stopping them from doing what they would usually do. It can also be associated with other problems, such as headaches, muscle aches, sleep disturbance as well as problems with concentration and memory. Unfortunately there is no test we can do that confirms the diagnosis, and it is often a diagnosis made if we can’t find any other cause.
There are things that can be done to help the symptoms, and most people will improve over time. We generally recommend a referral to a chronic fatigue clinic, as they have access to specialist physiotherapists / psychotherapists, who can help you along the road to recovery.
Management
Refer adults with symptoms suggestive of chronic fatigue syndrome/myalgic encephalomyelitis to specialist CFS/ME services:
Consider referring to secondary care those people with persistent, unexplained tiredness/fatigue not meeting the criteria for CFS/ME if any of the following apply:
There is significant uncertainty regarding the underlying cause, the patient would benefit from the reassurance of a second opinion or the patient may benefit from access to the multidisciplinary care delivered by specialist CFS/ME services.
Children and young people 17 years of age or younger should be referred to paediatrics within 6 weeks of presentation.
Treatment Strategies:
- Establish a supportive relationship.
- Offer an understandable explanation for tiredness/fatigue that offers ways for the person share responsibility for managing the symptoms.
- Provides links between psychosocial and physical factors.
- Identify and address modifiable psychological, social, and general health factors, including stress, work, personal relationships, pain, and alcohol.
For people meeting criteria for CFS/ME who have not yet been assessed by specialist CFS/ME services:
- Offer advice on sleep management.
- Provide general advice on sleep hygiene — see the section on Good sleep hygiene in the CKS topic on Insomnia.
- Discourage excessive sleep and daytime sleeping or naps.
- In relation to activity, rest, and relaxation, advise:
- Thinking about graded exercise therapy: starting low and building up slowly - this will often be done under supervision at the CFS/ME clinic.
- Limiting the length of rest periods to 30 minutes at a time.
- Avoiding unsupervised, or unstructured, vigorous exercise.
- Using relaxation techniques.
- Advise a well-balanced diet.
- Manage nausea by giving advice on eating little and often, snacking on dry starchy foods, and sipping fluids.
NICE is currently working on an updated version of its CFS / ME guidelines, due out soon.