How do I work up a patient with fatigue in an urgent care setting, differentiating between normal and abnormal fatigue?

Approach to Fatigue Workup in Urgent Care

In urgent care settings, fatigue evaluation should begin with quantitative assessment using a 0-10 scale, where scores ≥4 warrant further workup, while scores <4 can be managed with education and follow-up. 1

Initial Assessment

Quantitative Fatigue Screening

• Ask patient: "How would you rate your fatigue on a scale of 0 to 10 over the past 7 days?"
• Alternatively: Rate fatigue as none, mild, moderate, or severe
• Interpretation:
  • 0-3 (mild): Requires minimal workup
  • 4-10 (moderate to severe): Requires focused evaluation
  • ≥7: Associated with marked decrease in physical functioning 1

For Mild Fatigue (0-3)

• Provide education on fatigue management
• Recommend regular physical activity including stretching and aerobic exercise 2
• Schedule follow-up for reassessment
• No extensive laboratory workup needed

Focused Evaluation for Moderate to Severe Fatigue (4-10)

Key History Elements

1. Onset and pattern:

   • Acute vs. chronic (>6 months)
   • Constant vs. intermittent
   • Timing during day
   • Recent changes in severity

2. Associated symptoms:

   • Pain
   • Sleep disturbances
   • Emotional distress (anxiety, depression)
   • Cognitive issues
   • Unintentional weight loss
   • Pulmonary complaints 1

3. Red flags requiring urgent attention:

   • Significant unintentional weight loss
   • Night sweats
   • Fever
   • Focal neurologic symptoms
   • Chest pain or shortness of breath 3

4. Functional impact:

   • Effect on daily activities
   • Work performance
   • Social relationships 2

5. Medication review:

   • Prescription medications
   • Over-the-counter medications
   • Supplements 1

Physical Examination Focus

• Vital signs (including orthostatics)
• Cardiopulmonary examination
• Neurological examination
• Lymph node examination
• Skin examination for pallor or rashes 3

Laboratory Testing

• Laboratory studies affect management in only 5% of patients 2
• For moderate-severe fatigue, consider:
  • Complete blood count
  • Basic metabolic panel
  • Thyroid-stimulating hormone
  • Liver function tests
  • If clinically indicated: inflammatory markers (ESR, CRP)
  • Consider ferritin in menstruating women 4, 3

Management Approach

For Secondary Fatigue

• Identify and treat underlying conditions:
  • Anemia
  • Hypothyroidism
  • Depression/anxiety
  • Sleep disorders
  • Medication side effects 2, 3

For Physiologic Fatigue

• Structured exercise plan (walking program)
• Sleep hygiene education
• Stress management techniques
• Short naps (proven performance enhancers) 2

For Chronic Fatigue/ME/CFS

• Screen for post-exertional malaise
• Consider cognitive behavioral therapy
• Activity pacing rather than progressive exercise
• Symptom-based management 3

Common Pitfalls to Avoid

1. Over-investigation: Repeating normal laboratory tests rarely yields new diagnoses 2, 4

2. Dismissing psychological factors: Psychological causes should be considered in all fatigue patients, not as a diagnosis of exclusion 5

3. Inadequate follow-up: Schedule regular follow-up visits rather than sporadic urgent appointments 2

4. Mismanaging ME/CFS: Exercise can worsen symptoms in patients with post-exertional malaise 3

5. Missing serious underlying conditions: Pay special attention to red flags suggesting malignancy, infection, or other serious disease 4, 3

In urgent care, the goal is to identify patients needing immediate intervention versus those who can be managed with supportive care and outpatient follow-up. This structured approach allows for efficient triage while ensuring potentially serious causes of fatigue are not missed.