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Clinical Interview Patient History (specify items when possible)
1. Pre-onset environmental events:
Infectious exposure or events □ minor infections, □ immunization, □ upper respiratory infections,
□ sinusitis, □ pneumonia, □ gastrointestinal illness after sinusitis or pneumonia, □ dental infections,
□ vaginal infection, cystitis, □ prostatitis, □ blood transfusion
Exposure to: □ sick people, □ unfamiliar infectious agents when travelling, particularly following
vaccinations, □ contaminated water, □ poor quality recycled air
Non-infectious exposure or events: □ post-chemical toxins, □ heavy metals, □ moulds; □ severe
physical trauma e.g. whiplash/spinal injury/surgery, □ anaesthetics, □ undue stress, □ steroids
(before/during acute respiratory illness can turn immune response to Th2 and suppress T cell numbers)
Onset: date ___________________________________
□ sudden,________________ □ gradual; ______________ □ infectious_____________ □ other_______________
Symptoms at onset (indicate interrelated clusters if possible)
_________________________________________________________________________________________________________________________
Severity of symptoms at onset ______________________________________________________________________________________
Duration of Symptoms_______________________________________________________________________________________________
_________________________________________________________________________________________________________
2. Medical History
________________________________________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Immunizations & sensitivities ________________________________________________________________
Other therapies: ___________________________________________________________________________
3. Past history:
Pre-illness functioning _________________ %
Premorbid activity level ________________%
4. Family history ___________________________________________________________________________________ Systems
Review: Many symptoms involve more than one system. Be alert to the following & specify when possible:
Neurological:
□ cognition:
□ difficulty processing information,
□ difficulty organizing tasks,
□ difficulty remembering
□ information overload,
□ short term memory loss
□ pain:
□ headaches,
□ musculoskeletal pain,
□ worsens with physical or cognitive exertion
□ sleep disturbance:
□ disturbed sleep pattern,
□ unrefreshed sleep: quantity ____ hr., quality (1-10) _______
□ neurosensory & perceptual disturbance:
□ sensory overload,
□ motor disturbance ______________________ wendy boutilier, artzstudios1
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Immune:
□ recurrent flu-like symptoms that activate/worsen with exertion,
□ susceptible to repeated infections GI:
□ nausea,
□ abdominal pain,
□ bloating,
□ IBS,
□ food &/or alcohol sensitivities,
□ chemical sensitivities (specify) ___________________________________________________________________________ GU:
□ urinary urgency, □ frequency, □ nocturia
Energy production/ion transport Cardiovascular:
□ orthostatic intolerance (OI) - inability to tolerate upright position,
□ neutrally mediated hypotension (NMH),
□ postural orthostatic tachycardia syndrome POTS),
□ palpitations with or without cardiac arrhythmias,
□ light headedness ________________________________________________
Respiratory: □ air hunger, □ laboured breathing, □ fatigue of chest wall muscles
Endocrine & ANS: □ loss of thermostatic stability, □ intolerance of extremes of temperature
Post-exertional neuroimmune exhaustion (PENE) (Cardinal Symptom)
□ Marked, rapid physical or cognitive fatigability in response to exertion
□ Symptoms that worsen with exertion ___________________________________________________________________________
□ Post-exertional exhaustion: □ immediate, □ delayed; □ prolonged recovery period □ Exhaustion is not
relieved by rest ________________________________________________________________________________________
□ Substantial reduction in pre-illness activity level due to low threshold of physical and mental fatigability
(lack of stamina) ____________
Activity level: □100%, □90%, □80%, □70%, □60%, □50%, □40%, □30%, □20%, □10%
Symptom hierarchy, quality & severity __________________________________________________________________________
Secondary symptoms & aggravators _____________________________________________________________________________
Sleep quality: scale of 1-10 (excellent sleep 10): ______, onset______, duration ______, problems _______________
Pain: scale of 1-10 (worst pain ever 10): _______________, problems
________________________________________________________
Energy/fatigue: scale of 1-10 (great energy 10): good day ____________, bad day ____________, today _________
Physical Examination: Standard examination with attention to: temp. _______; pH: _______; BP/pulse:______
1. lying down: BP _______/_______, Pulse ________;
2. immediately after standing: BP _____/_____, Pulse ______;
3. after standing 3 min.: BP _____/_____, Pulse _____ ;
4. after standing 5 min.: _______/_______, Pulse ________ (Caution: Someone should stand beside the patient.)
Neurological CNS:
Reflex examination: (neck flexion & extension may accentuate abnormalities from cervical myelopathic
changes)
Neurocognitive: □ slowed thought, □ impaired concentration, □ difficulty remembering questions;
□ cognitive fatigue: during assessment, serial 7 subtraction (subtracting by 7 from 100)_____________________
□ cognitive interference: (e.g. serial 7 subtraction done simultaneously with tandem walk) _________________
wendy boutilier, artzstudios1
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Pain/musculoskeletal:
□ hyperalgesia, □ widespread, □ myofascial or radiating, □ muscle-tendon junctions, □ taut muscles;
joints: □ inflammation, □ hypermobility, □ restricted movement; positive tender points ____/18;
□ meets fibromyalgia criteria; muscle tone: □ paretic, □ spastic; muscle strength ____________________________
Neurosensory, perceptual and motor disturbance: □ abnormal accommodation responses of the
pupils, □ suborbital hyperpigmentation; tandem walk: □ forward, □ backwards; □ Romberg test;
□ reflex examination _______________________________________
Immune: Tender lymphadenopathy: □ cervical, □ axillary, □ inguinal regions (more prominent in acute
phase), □ flares with exertion; □ crimson crescents in the tonsillar fossa: □ demarcated along margins of
both anterior and pharyngeal pillars, □ if patient has no tonsils, they assume a posterior position in the
oropharynx; □ splenomegaly
GI: □ increased bowel sounds, □ abdominal bloating, □ abdominal tenderness: epigastrium (stomach),
right lower quadrant (terminal ileum) and left lower quadrant (sigmoid colon) – most patients have
tenderness in 2-3/3 areas
Cardiovascular & respiratory: □ arrhythmias: □ BP as above; □ mottling of extremities, □ extreme
pallor, □ Raynaud’s phenomenon, □ receded moons of finger nails (chronic phase) _________________
Laboratory/Investigative Protocol: Diagnose by criteria. Confirm by laboratory and other
investigations. A broad panel of tests provides a more robust basis to identify symptom patterns,
abnormalities and orient treatment.
Routine laboratory investigation:
□ CBC, □ ESR, □ CA, □ P, □ RBC Mg, □ vitamin D3, □ B12 & folate, □ ferritin, □ zinc, □ FBS, □ PC,
□ Hb A1C, □ serum electrolytes, □ TSH, □ protein electrophoresis screen, □ CRP, □ creatinine, □ ECG
(U+ T wave notching), □ CPK and liver function, □ rheumatoid factor, □ antinuclear antibodies,
□ urinalysis, □ essential fatty acids, □ CoEnzyme Q10, □ immunoglobulins, □ diurnal cortisol levels,
□ TTG, □ serotonin
Additional laboratory investigation: (as indicated by symptoms, history, clinical evaluation, lab
findings, risk factors) □ 24 hour urine free cortisol, □ DHEA sulphate, □ ACTH, □ chest x-ray
□ hormones including free testosterone □ panoramic x-ray of dental roots, □ amino acid profile,
□ abdominal ultra sound, □ lactose/fructose breath test.
Further testing with specificity to ME, if and as indicated. Some tests are in the research stage but can
identify abnormalities and focus treatment. Viral tests should be interpreted by a physician experienced
in these infections.
Pathogen Tests Pathogen Tests
□ Enterovirus RT-PCR, serology, stomach biopsy
□ mycoplasma DNA-PCR, serology □ EBV, □ CMV, □ HHV-6 DNA-PCR, serology, antigenemia
□ Borrelia burgdorferi DNA-PCR, serology, Western Blot Clamydia pneumonia DNA PCR, serology
□ Parvovirus B19 DNA-PCR, IgG, IgM,
Immune system profiles:
□ NK cell function & Cytotoxicity; □ B & T-cell function: □ IgG, □ IgG subclasses 1-4;
□ IgA, □ IgM (shift from T1 to T2), □ cytokine/chemokine profile panel (94% accuracy): IL-8, IL-13,
MIP-1β, MCP-1, IL4, □ flow cytometry for Lymphocyte activity,
□ 37 kDa 2-5A RNase L immunoassay – defect/ratio & bioactivity, □ food sensitivity panel, □ chemical
sensitivities, □ stool for WCB - D-lactic acid bacteria balance, ova & parasites,
□ autoimmune profile, Intestinal dysbiosis: □ IgA & IgM for intestinal aerobic bacteria in serum,
□ leukocyte elastase activity in PBMCs, □ IgG food intolerance test, □ toxoplasmosis
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wendy boutilier, artzstudios1
Neurological & static testing:
□ *SPECT scan with contrast - cortical/cerebellar region cerebral blood flow (rCBF) in the frontal,
parietal, temporal and occipital & brain stem regions - more brain involvement indicates increased illness
severity,
□ MRI of brain – (increased T2-weighted images in high white matter tracts & loss of GM volume) & rule
out MS, □ MRI of spine (dynamic disc bulges/herniation , stenosis),
□ sleep study ( stage 4 sleep, sleep pattern & rule out treatable sleep dysfunctions – upper airway
resistance syndrome, sleep apnea, etc.)
PENE:
A 2 consecutive day comprehensive 8-12 minute cardiopulmonary exercise stress test (measuring heart,
lung, and metabolic function) - only ME patients have significantly worse scores the second day &
abnormal recovery from exertion. Exercise tolerance test with expired gas exchange - (2 consecutive
days) – measure cardiovascular, pulmonary & metabolic responses at rest & during
exercise:____________________________________________________________________________________________________________
□ peak oxygen consumption VO2 or VO2 at anaerobic threshold (AT) - decline of 8% or greater on test 2
indicates metabolic dysfunction,
□ post-exercise blood analysis - increase in sensory, adrenergic and immune genes - increase in
metabolite receptors unique to ME.
Energy metabolism/ion transport:
□ ATP profile – identifies insufficient energy due to cellular respiration dysfunction
□ further ATP related parameters, superoxide dismutase and cell-free DNA Respiratory:
□ pulmonary function test Cardiovascular:
□ Tilt table test to confirm OI (70 -80% tilt, measure HR continuously, BP periodically – 30 min or
presyncope);
□ Cardiac output decreases - left ventricular dysfunction in the heart;
□ 24-Hour Monitor for suspected Arrhythmia, NMH/POTS, Myocarditis (Note: Repetitively oscillating T- wave inversions &/or T-wave flats, typical of ME, may be subsumed under non-specific T-wave changes.)
Differential Diagnosis:
When indicated on an individual basis, rule out other diseases that could plausibly simulate the
widespread, complex, symptom pathophysiology defining ME. E.g.: Infectious disorders: TB, AIDS, Lyme,
Chronic Hepatitis, Endocrine Gland Infections; Neurological: MS, Myasthenia Gravis, B12;
Autoimmune disorders: polymyositis & polymyalgia rheumatica, rheumatoid arthritis; Endocrine:
Addison’s, Hypo & Hyper Thyroidism, Cushing’s Syndrome; Cancers; Anemias: Iron Deficiency, B12
[megaloblastic]; Diabetes Mellitus; Poisons
Exclusions: Primary psychiatric disorders, somatoform disorder, substance abuse & paediatric ‘primary’
school phobia.
Comorbid Entities: Myofascial Pain Syndrome, TMJ, Interstitial Cystitis, Raynaud’s Phenomenon,
Prolapsed Mitral Valve, Irritable Bladder Syndrome, Prolapsed Mitral Valve, Hashimoto’s Thyroiditis, Sicca
Syndrome, Secondary Depression, Allergies, MCS, etc. FMS is an overlap condition. IBS & Migraine may
precede ME and then become associated with it.