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

Workup and Treatment for Chronic Fatigue Syndrome

A comprehensive evaluation for chronic fatigue syndrome should include screening for fatigue severity, focused history and physical examination, assessment of treatable contributing factors, and implementation of evidence-based interventions including physical activity and cognitive behavioral therapy.

Initial Assessment

Fatigue Screening

• Use a numeric rating scale (0-10) to quantify fatigue severity:
  • Mild: 1-3 (minimal intervention needed)
  • Moderate: 4-6 (requires evaluation)
  • Severe: 7-10 (requires immediate intervention) 1
• Alternative: Rate fatigue as none, mild, moderate, or severe 1

Focused History and Physical Examination

For patients with moderate to severe fatigue (score ≥4), conduct:

1. Detailed fatigue assessment:

   • Onset, pattern, duration, and changes over time
   • Associated or alleviating factors
   • Interference with daily function 1

2. Review of systems to identify:

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

3. Medication review:

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

Evaluation of Treatable Contributing Factors

Medical Causes

• Laboratory testing (targeted, not extensive):
  • Complete blood count (anemia)
  • Thyroid function tests
  • Basic metabolic panel
  • Liver function tests 2
  • Additional testing based on clinical suspicion

Common Contributing Factors

1. Pain - Assess location, intensity, and impact on function
2. Emotional distress - Screen for depression and anxiety
3. Sleep disturbance - Evaluate sleep quality, duration, and hygiene
4. Anemia - Check hemoglobin levels
5. Nutrition - Assess dietary intake and nutritional status
6. Activity level - Determine current physical activity patterns
7. Medication side effects - Review for sedating medications
8. Alcohol/substance abuse - Screen for use patterns
9. Comorbidities - Identify concurrent medical conditions 1

Treatment Approach

Non-pharmacological Interventions

1. Physical Activity (Category 1 recommendation) 1

   • Begin with structured, regular exercise program
   • Start with gentle stretching
   • Progress to regular aerobic exercise (e.g., walking)
   • Gradually increase duration and intensity

2. Cognitive Behavioral Therapy 3

   • Address catastrophic misinterpretations of symptoms
   • Develop consistent patterns of activity and rest
   • Problem-solve current life difficulties
   • Establish realistic expectations

3. Sleep Management

   • Maintain consistent sleep schedule
   • Practice good sleep hygiene
   • Short naps (20-30 minutes) can enhance performance 2

4. Education and Counseling

   • Explain typical patterns of fatigue
   • Teach energy conservation techniques
   • Set reasonable expectations for improvement 1

Pharmacological Interventions

1. For depression/anxiety if present:

   • Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, or sertraline may improve energy levels 2

2. For specific situations requiring alertness:

   • Caffeine (short-term use)
   • Modafinil (for specific circumstances) 2

3. Avoid unnecessary medications that may worsen fatigue 4

Follow-up and Monitoring

• Schedule regular follow-up visits rather than sporadic urgent appointments 2
• Reassess fatigue levels at each visit
• Adjust treatment plan based on response
• Continue monitoring even after initial improvement

Common Pitfalls to Avoid

1. Excessive laboratory testing - Initial normal results rarely change with repeated testing 2

2. "Fishing expeditions" - If medical causes aren't evident initially, extensive additional testing is usually fruitless 5

3. Dismissing symptoms - Chronic fatigue is a legitimate condition requiring proper management

4. Focusing only on physical or only on psychological factors - Both domains require attention

5. Inconsistent activity patterns - Irregular bursts of activity followed by prolonged rest can perpetuate fatigue 4

By following this structured approach to evaluation and management, most patients with chronic fatigue syndrome can experience meaningful improvement in symptoms and quality of life.