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Several body systems are located diffusely or within multiple regions of the body. As a result, the clinician assesses these systems continuously throughout the examination to a greater extent than the more localized systems. Although disease predominately arising in a single body system can present with constitutional symptoms, this is generally more true of the systems discussed here. It is important to keep these systems in mind throughout the examination process. Diseases and syndromes within these systems are exemplars of the need to integrate the findings from all parts of the diagnostic examination into your hypothesis generating process. This concept is reflected in the century-old saying that “he, who knows syphilis, knows medicine.”
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Constitutional Symptoms
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Constitutional symptoms are those that relate to the body or person as a whole, generally excluding psychological symptoms. Many of these symptoms are very nonspecific, but may be clues to serious systemic illness. Because of their nonspecific nature, they must be combined with physical examination findings and laboratory tests before a specific set of physiologic and diagnostic hypotheses can be generated. It may, however, be possible to posit a class or two of general physiologic processes. For instance, the middle-aged patient who presents with anorexia, weight loss, and night sweats suggests the presence of neoplastic or chronic infectious or inflammatory disease, or possibly Addison disease.
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Fatigue is a nonspecific symptom that can result from serious organic disease, neuropsychiatric disease, or deconditioning. Patients describe decreased energy, decreased endurance for normal activities, and a feeling of increased effort in usual tasks. Clinical fatigue incorporates three components, present to variable degrees in individual patients: inability to initiate activity (perception of generalized weakness, in the absence of objective findings); reduced capacity to maintain activity (easy fatigability); and difficulty with concentration, memory, and emotional stability (mental fatigue). It is important to distinguish fatigue from shortness of breath, muscle weakness and excessive sleepiness. Fatigue can complicate any chronic disease or medical condition; especially common causes are anemia, hypothyroidism, and hyperthyroidism, autoimmune and neurologic disorders [Chaudhuri A, Behan PO. Fatigue in neurological disorders. Lancet. 2004;363:978–988]. DDX: History should determine the severity and temporal pattern of fatigue as follows: Onset—abrupt or gradual, related to event or illness? Course—stable improving or worsening? Duration and daily pattern? Factors that alleviate or exacerbate symptoms? Impact on daily life? Symptoms suggesting underlying occult medical illness should be explored in a detailed review of systems, including presence of weight loss or night sweats. The history should also include questions screening for psychiatric disorders (particularly depression, anxiety disorders, somatoform disorders, and substance abuse). When a complete history, physical examination, and screening laboratory evaluation do not find a specific explanation consider deconditioning, depression, sleep disorders, and chronic fatigue syndrome. CLINICAL OCCURRENCE: These are examples only. Congenital: Muscular dystrophies, mitochondrial myopathy; Endocrine: Hypothyroidism, hyperthyroidism, Addison disease, hypopituitarism, hypoparathyroidism, hypogonadism; Idiopathic: Chronic fatigue ...