What is the appropriate physical exam for a patient presenting with fatigue?

Physical Examination for Fatigue

A comprehensive physical examination for fatigue should include a focused assessment of vital signs, cardiopulmonary, neurological, and skin examinations, along with screening for common contributing factors such as pain, emotional distress, sleep disturbance, anemia, nutritional status, and medication side effects. 1

Initial Fatigue Assessment

First, quantify the severity of fatigue:

• Use a numeric rating scale (0-10) or categorical scale (none, mild, moderate, severe)
• Scores ≥4 or moderate-severe fatigue require thorough evaluation
• Fatigue levels ≥7 correlate with marked decrease in physical functioning 2

Focused History Components

Before physical examination, obtain:

• Onset, pattern, duration, and changes in fatigue over time
• Associated or alleviating factors
• Interference with daily function and activities
• Patient's self-assessment of potential causes 2

Physical Examination Elements

Vital Signs

• Blood pressure and heart rate (cardiac disease)
• Respiratory rate (pulmonary disease)
• Temperature (infection, inflammatory conditions)
• Weight (unintentional weight loss may indicate malignancy)

Organ System Assessment

1. Cardiopulmonary Examination

   • Heart sounds, murmurs, rhythm (cardiac disease)
   • Lung fields for crackles, wheezes (pulmonary disease)
   • Peripheral edema (heart failure)

2. Neurological Examination

   • Mental status (cognitive impairment, depression)
   • Cranial nerves
   • Motor strength and tone
   • Sensory function
   • Deep tendon reflexes
   • Coordination

3. Skin Examination

   • Pallor (anemia)
   • Rashes (autoimmune conditions)
   • Jaundice (liver disease)

4. Thyroid Examination

   • Palpation for enlargement or nodules
   • Particularly important in patients with radiation to neck/thorax 2

5. Lymph Node Examination

   • Cervical, axillary, and inguinal lymphadenopathy (infection, malignancy)

6. Abdominal Examination

   • Hepatomegaly or splenomegaly
   • Masses or tenderness

Assessment of Treatable Contributing Factors

The physical exam should specifically assess for these nine common causes of fatigue 2:

1. Pain - Musculoskeletal examination for tender points, joint swelling
2. Emotional distress - Signs of depression or anxiety
3. Sleep disturbance - Signs of sleep apnea (obesity, enlarged tonsils)
4. Anemia - Pallor, tachycardia
5. Nutritional status - BMI, muscle wasting
6. Activity level - Muscle tone, strength
7. Substance abuse - Signs of alcohol/drug use
8. Medication side effects - Review current medications
9. Comorbidities - Signs of cardiac, pulmonary, or endocrine disease

Special Considerations

For patients with cancer history:

• More extensive workup when moderate-severe fatigue begins after or worsens 6-12 months post-treatment
• Include echocardiogram for patients who received cardiotoxic treatments
• Include thyroid screening for patients who received radiation to neck/thorax 2

Clinical Pitfalls to Avoid

1. Assuming fatigue is solely due to psychological causes - studies show diverse diagnoses including musculoskeletal (19.4%) and psychological problems (16.5%) 3

2. Excessive testing without clinical indication - a clinically directed approach is more cost-effective than extensive "fishing expeditions" 4, 5

3. Failing to recognize post-exertional malaise in patients with possible ME/CFS - this is the cardinal symptom requiring specific management approaches 1

4. Discounting patient attributions - there is often low agreement between patient and provider causal attributions for fatigue 6

Remember that while most patients with fatigue do not have serious underlying pathology (only 8.2% in one study) 3, a systematic physical examination is essential to identify treatable causes and guide appropriate management.