What is the approach to evaluating and managing a patient presenting with fatigue?

Comprehensive Approach to Evaluating and Managing Fatigue

A systematic evaluation of fatigue should begin with screening for severity, followed by a focused assessment of contributing factors, laboratory testing, and targeted interventions based on identified causes. 1

Initial Screening and Assessment

Severity Assessment

• Use a quantitative scale (0-10 numeric rating scale) to assess fatigue severity:
  • Mild: 1-3
  • Moderate: 4-6
  • Severe: 7-10 1
• For moderate to severe fatigue (score ≥4), proceed with comprehensive evaluation

Focused History

1. Fatigue characteristics:

   • Onset, pattern, duration
   • Change over time
   • Associated or alleviating factors 1

2. Review of systems to identify potential underlying causes 1

3. Assessment of treatable contributing factors:

   • Pain
   • Emotional distress (depression, anxiety)
   • Sleep disturbance
   • Anemia
   • Nutritional status
   • Activity level
   • Alcohol/substance abuse
   • Medication side effects
   • Comorbidities 1

Physical Examination

Focus on identifying:

• Signs of anemia (pallor)
• Cardiopulmonary abnormalities
• Neurological deficits
• Thyroid abnormalities
• Evidence of infection
• Signs of malignancy 2

Laboratory Evaluation

Laboratory testing should be guided by clinical findings rather than performed as an extensive battery, as studies show only 5% of laboratory studies affect management in patients with fatigue 3, 4.

Basic Laboratory Panel

• Complete blood count with differential
• Comprehensive metabolic panel (electrolytes, renal and hepatic function)
• Thyroid-stimulating hormone (TSH) 1

Additional Testing Based on Clinical Suspicion

• Inflammatory markers (ESR, CRP) if infection or inflammatory condition suspected
• Additional endocrine testing if indicated
• Consider specialized testing based on specific symptoms 1, 2

Management Approach

Address Treatable Contributing Factors

1. Medical conditions: Treat underlying conditions (anemia, hypothyroidism, etc.)
2. Medications: Review and adjust medications with sedating side effects
3. Substance use: Address alcohol or substance abuse
4. Nutrition: Correct nutritional deficiencies
5. Sleep disorders: Implement sleep hygiene measures 1

Interventions for Persistent Fatigue

Non-pharmacological Approaches

1. Physical activity:

   • Structured exercise program with gradual progression
   • 150 minutes of moderate aerobic activity per week plus 2-3 strength training sessions
   • Start with low-level activities and gradually increase 1, 3

2. Energy conservation strategies:

   • Prioritize important activities
   • Plan rest periods
   • Delegate tasks when possible 1

3. Cognitive behavioral therapy for chronic fatigue 3, 2

4. Sleep hygiene measures:

   • Regular sleep schedule
   • Limit daytime napping to short periods (20-30 minutes)
   • Avoid caffeine and alcohol before bedtime 3

Pharmacological Approaches

• Selective serotonin reuptake inhibitors if depression is present
• Treat specific underlying conditions
• Caffeine or modafinil may be considered for episodic situations requiring alertness 3

Special Considerations

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

• Key feature is postexertional malaise
• Exercise may worsen symptoms
• Focus on pacing activities to conserve energy 2

Cancer-Related Fatigue

• Highly prevalent during and after cancer treatment
• May persist long after treatment completion
• Requires specialized assessment and management approach 1

Follow-up

Schedule regular follow-up visits rather than sporadic urgent appointments for effective long-term management 3.

Common Pitfalls to Avoid

1. Excessive laboratory testing: Initial normal results rarely change with repeat testing 4
2. Attributing all fatigue to depression without adequate evaluation for physical causes
3. Recommending increased exercise for patients with ME/CFS (may worsen symptoms) 2
4. Dismissing fatigue as "normal" without adequate evaluation
5. Failing to recognize medication side effects as potential causes of fatigue 1