Chronic Fatigue Syndrome

Casebank Counselling
1

Who you are:
You are an FY2 in a GP clinic.

Who the patient is:
Mrs. Julia Andresen, 35-year-old, presented to the GP surgery 6 months ago with tiredness. She has come for her follow up.

Special notes
IT has crashed and his records are not available.

What you should do:
Take a history from her and talk to her about further management.

Chronic fatigue syndrome: tiredness more than 6 months + flu like symptoms before the tiredness + without joints pain.
It is a disease of exclusion.

Build Rapport:
D: I can see from my notes that you’re here for your follow up, how are you doing so far?
P: This tiredness is getting worse doctor.

ODIPARA:
D: I am sorry to hear that, can you tell me more about it?
P: I came 6 months ago for tiredness; the doctor ran some investigations, but I don’t know the results. (+ve finding)
D: Unfortunately, our IT system has crashed which means I can’t reach your profile right now; I am really sorry about that.
P: Does this mean all my data’s gone?
D: No, it’s just temporary. Has the other doctor told you what may be causing your tiredness?
P: No, he didn’t find any cause for it.
D: Is there anything making it worse or better?
P: No.
D: Apart from this, is there anything else?
P: No.
D: What’s your main worry?
P: I want to know what’s wrong with me.

PSYCHOSOCIAL
D: You told me that you have had this condition for 6 months now, how is this affecting your life?
P: It started to affect my relations with my wife, I am too tired to have sex with her and she thinks I am cheating on her. (+ve finding)
D: Oh no! That’s not good at all. And is this affecting your work?
P: I am a lawyer and I find it difficult to concentrate, I am afraid I could lose my job. (+ve finding)
D: Sound like you’re going through a difficult time. Is it affecting your mood?
P: It’s difficult, but I think I am ok mood-wise.
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the happiest, can you grade your mood for me?
P: It would be 6.

DIFFERENTIALS:
D: Any weight changes recently?
P: No.
D: Any fever?
P: I had flu like symptoms before getting this tiredness
D: OK, do you have any fever now?
P: No.
D: Do you feel hot when other people feel cold and vice versa?
P: No.
D: Do you go to the loo more often than usual?
P: No.
D: Any joint pain or stiffness?
P: No.

P2:
D: Have you had this tiredness before?
P: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Do you have any medical condition?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No.

DESA
D: Can you tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: What about alcohol?
P: Just occasionally.

Examination

Provisional diagnosis:
The exact cause of your tiredness is unknown, especially seen as I’m not able to get into the system to check your results right now. However, I think you may have chronic fatigue syndrome. It’s a chronic condition which causes your body and mind to feel exhausted, without having done any physical activity.

Management
• Senior.
• Investigations.
• Blood (all tests for tiredness) and urine tests. To rule out other conditions that could be causing your symptoms.

Lifestyle changes

  • Diet -It’s important that you eat regularly and have a healthy, balanced diet. If you feel sick (nauseous), eating little and often, may help. If this does not work, medicine can be prescribed. Diets that exclude certain food types are not recommended.
  • Sleep, rest and relaxation. You may have sleep problems (unrefreshing or restless sleep or excessive amount of sleep) that make your CFS symptoms worse. You should be given advice about how to establish a normal sleeping pattern.
  • Limiting rest period during the day to 30 minutes could help.
  • Relaxation techniques, such as breathing exercises.

Symptomatic

  • Treatments for CFS aim to help relieve your symptoms.
  • Your treatment will be tailored to your symptoms.
  • CFS can last a long time, but most people’s symptoms will improve with time.
  • We should discuss all the options with you and explain the benefits and risks of any treatment taking into account your circumstances and preferences.
  • Medicine can be used to relieve some of the symptoms.
  • Over-the-counter painkillers can help ease headaches, as well as muscle and joint pain.
  • You may be referred to a pain management clinic if you have long-term pain.
  • Antidepressants can be useful for pain or having trouble sleeping.
  • Amitriptyline may be prescribed to help ease muscle pain.

Specialist treatments
There are several specialist treatments for CFS.

  1. Cognitive behavioural therapy (CBT) - For mild or moderate CFS.
    CBT is a talking treatment that can help you manage CFS by changing the way you think and behave.
    It can help you to: accept your diagnosis and feel more in control of your symptoms.
    Using CBT does not mean CFS is a psychological condition.
    It’s used to treat a variety of long-term conditions.

  2. Graded exercise therapy (GET)
    It is a structured exercise program that aims to gradually increase how long you can carry out a physical activity.
    It usually involves exercise that raises your heart rate, such as swimming or walking.
    Your exercise program will be adapted to your physical capabilities.
    GET should only be carried out with the help of a trained specialist with experience in treating CFS.

  3. Activity management
    It involves setting individual goals and gradually increasing your activity levels.
    You may be asked to keep a diary of your current activity and rest periods to establish your baseline. Activities can then be gradually increased in a way you find manageable.

  4. Changes in your place of work, study or home.

Safety netting

  • If you have severe CFS and need to spend much of your time in bed, it can cause problems, including pressure sores and blood clots. These problems, and how to avoid them, should be explained to you and your carers.
  • If you feel low due to your symptoms, come to us immediately.

Follow up
Your treatment plan would be reviewed regularly.