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

Workup and Management of Chronic Fatigue

A comprehensive evaluation of 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 Screening

• Ask patient: "How would you rate your fatigue on a scale of 0 to 10 over the past 7 days?" 1
  • Scores 0-3: Mild fatigue - requires minimal intervention
  • Scores 4-10: Moderate to severe fatigue - requires comprehensive evaluation
  • Note: Scores ≥7 correlate with marked decrease in physical functioning 1

Focused History

For moderate to severe fatigue (score 4-10), obtain:

• Onset, pattern, duration, and change over time
• Associated or alleviating factors
• Interference with daily function and activities
• Patient's self-assessment of potential causes 1

Physical Examination

• Complete review of systems to identify affected organ systems
• Focused physical exam based on symptoms 1

Evaluation for Treatable Contributing Factors

Systematically assess these 9 key factors that commonly cause or exacerbate fatigue:

1. Pain - Often clusters with fatigue; requires effective management 1
2. Emotional distress - Depression occurs in up to 33% of fatigued patients 1
3. Sleep disturbance/poor sleep hygiene - Common contributor to fatigue 1
4. Anemia - Complete blood count to evaluate 1
5. Nutritional deficiencies - Assess intake, weight changes 1
6. Activity level - Both excessive and insufficient activity can contribute 1
7. Medication side effects - Review all prescriptions, OTC medications, and supplements 1
8. Alcohol/substance abuse - Screen for use patterns 1
9. Comorbidities - Particularly:
   • Thyroid dysfunction (TSH)
   • Cardiac disease
   • Underlying malignancy
   • Infection 1

Laboratory Testing

Based on clinical suspicion, consider:

• Complete blood count
• Comprehensive metabolic panel
• Thyroid stimulating hormone
• Inflammatory markers (ESR, CRP)
• Additional testing only if clinically indicated 2

Note: Laboratory studies affect management in only 5% of patients with fatigue; if initial results are normal, repeat testing is generally not indicated 3

Management Approach

Treatment of Contributing Factors

• Address all identified contributing factors first 1
• Treat pain, depression, anemia, sleep disorders according to standard guidelines 1

Non-pharmacologic Interventions

1. Physical Activity

   • Structured, regular exercise program including:
     • Stretching
     • Aerobic exercise (e.g., walking)
   • Exception: For suspected myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), avoid exercise that may trigger post-exertional malaise 2

2. Cognitive Behavioral Therapy

   • Particularly effective for chronic fatigue 3, 4
   • Helps address catastrophic misinterpretation of symptoms 5

3. Energy Conservation Strategies

   • Consistent pattern of activity, rest, and sleep 5
   • Short naps (proven performance enhancers) 3

4. Sleep Hygiene Improvement

   • Regular sleep schedule
   • Avoidance of stimulants before bedtime 1, 3

Pharmacologic Interventions

• Selective serotonin reuptake inhibitors (e.g., fluoxetine, paroxetine, sertraline) - May improve energy in patients with depression 3
• Psychostimulants (e.g., methylphenidate) - May provide some benefit in selected cases 1
• Avoid unnecessary medications that may contribute to fatigue 5

Follow-up

• Schedule regular follow-up visits rather than sporadic urgent appointments 3
• Reassess fatigue levels and response to interventions
• Adjust management plan based on response 1

Special Considerations

Chronic Fatigue Syndrome/ME/CFS

• Key feature: Post-exertional malaise
• Exercise can be harmful in these patients
• Focus on pacing activities within energy limits 2
• No proven cure; treatment focuses on symptom management 2

Cancer-Related Fatigue

• May require specialized assessment and management
• Consider disease status and treatment effects 1

Common Pitfalls to Avoid

1. Dismissing fatigue as "just normal tiredness"
2. Excessive laboratory testing when initial results are normal
3. Recommending increased exercise for all patients (harmful in ME/CFS)
4. Failing to address psychological factors
5. Not providing a positive explanation of symptoms to patients 5