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By Karen Harman; Martin J Wiselka; John D Firth; Royal College of Physicians of London. Education Department

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Persistent symptoms. He does not have any symptoms to suggest that depression is the primary process. Following his first clinic attendance a standard range of tests are performed: • Chronic fatigue syndrome is real. • There is no specific drug therapy but there are treatment options, including graded exercise and cognitive therapy. FBC, inflammatory markers, electrolytes, glucose, renal/liver/ bone function tests, autoimmune/ Appropriate responses to likely questions vasculitic screen, thyroid function tests, serology for Epstein–Barr virus and cytomegalovirus, CXR and a short Synacthen test.

Is there evidence of lymphangitis? A red line tracking up the limb along the line of the lymphatic drainage confirms the presence of distal infection. • Is there tender lymphadenopathy at the proximal end of the affected limb? • Are there any areas of necrosis? If present you must immediately suspect necrotising fasciitis. This may not be immediately apparent in the early stages, but is suggested by very severe pain accompanied by discoloration and blistering of the skin. • Any evidence of crepitus within the affected area suggests gas within the tissues, indicating gas gangrene/necrotising fasciitis.

Midstream specimen of urine: bacterial culture. • Throat swab: culture for gonorrhoea. • Swab lesions: bacterial and viral culture. • Serology for hepatitis C. Blood tests Routine haematology and biochemistry are rarely helpful. Check urine for glycosuria and blood glucose in patients with severe candidal vulvitis or recurrent UTI. Serology can be used to confirm syphilis or HIV seroconversion illness and can also be of use in the uncommon condition of lymphogranuloma venereum. Management The following are principles underlying management.

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