What is the recommended workup and treatment for a patient presenting with chronic fatigue?

Workup for Chronic Fatigue

A comprehensive workup for chronic fatigue should begin with quantifying fatigue severity on a 0-10 scale, followed by a focused history, physical examination, and targeted laboratory testing to identify treatable contributing factors. 1

Initial Assessment

Fatigue Severity Screening

• Use a numeric rating scale (0-10) to assess fatigue severity:
  • 0-3: Mild fatigue - requires minimal intervention
  • 4-10: Moderate to severe fatigue - requires thorough evaluation
  • ≥7: Indicates marked decrease in physical functioning 2

Focused History

For patients with moderate to severe fatigue (score 4-10), conduct a detailed assessment of:

• Fatigue characteristics:

  • Onset, pattern, duration
  • Change over time
  • Alleviating/exacerbating factors
  • Interference with daily function 2

• Review of systems to identify:

  • Associated symptoms (pain, cognitive issues)
  • Unintentional weight loss
  • Pulmonary complaints
  • Sleep disturbances 2

Physical Examination

Focus on identifying signs of:

• Anemia
• Thyroid dysfunction
• Cardiac disease
• Respiratory disorders
• Neurological abnormalities 2

Laboratory and Diagnostic Workup

First-line Laboratory Tests

• Complete blood count (CBC)
• Comprehensive metabolic panel
• Thyroid function tests (TSH, free T4)
• Inflammatory markers (ESR, CRP)
• Urinalysis 1

Additional Testing (Based on Clinical Suspicion)

• Iron studies (ferritin, transferrin saturation)
• Vitamin B12 and folate levels
• Vitamin D level
• HbA1c
• Sleep study if sleep apnea suspected 2, 1

Assessment of Common Contributing Factors

Medical Conditions

• Anemia
• Hypothyroidism
• Cardiac disease
• Malignancy
• Infection (acute or chronic)
• Autoimmune disorders 2

Psychological Factors

• Depression (present in up to 33% of patients with fatigue)
• Anxiety
• Emotional distress 2

Lifestyle Factors

• Sleep disturbance/poor sleep hygiene
• Medication side effects
• Alcohol/substance use
• Nutritional deficiencies
• Physical deconditioning
• Work-life imbalance 2

Treatment Approach

Address Underlying Causes

• Treat identified medical conditions (anemia, hypothyroidism, etc.)
• Adjust medications that may contribute to fatigue
• Manage pain and emotional distress 2

Non-pharmacological Interventions

1. Physical Activity (Category 1 recommendation):

   • Implement a structured exercise program with gradual progression
   • Start with low to moderate intensity walking
   • Aim for 30-60 minutes, 2-3 times weekly 2
   • CAUTION: For suspected myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), avoid exercise that could trigger post-exertional malaise 1

2. Cognitive Behavioral Therapy:

   • Effective for addressing fatigue-perpetuating thoughts and behaviors
   • Helps develop coping strategies 3, 1, 4

3. Sleep Hygiene Improvement:

   • Regular sleep schedule
   • Limit daytime napping to short periods (20-30 minutes)
   • Avoid caffeine and alcohol near bedtime 5

4. Energy Conservation Techniques:

   • Activity pacing
   • Prioritization of tasks
   • Scheduled rest periods 2

Pharmacological Management

• Selective serotonin reuptake inhibitors for fatigue with depression
• Short-term corticosteroids may be considered in specific cases
• Avoid unnecessary medications 2, 5

Follow-up and Monitoring

• Schedule regular follow-up visits rather than sporadic urgent appointments
• Reassess fatigue severity at each visit
• Adjust treatment plan based on response 5

Common Pitfalls to Avoid

• Excessive laboratory testing if initial results are normal
• Attributing all fatigue to psychological causes without adequate medical workup
• Failing to recognize ME/CFS and recommending inappropriate exercise
• Dismissing fatigue without a clear diagnosis 1, 6

Remember that chronic fatigue often requires ongoing management rather than a quick fix. A systematic approach focusing on identifying and addressing contributing factors will lead to the best outcomes for patients with this challenging condition.