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

Workup and Management of Chronic Fatigue

The recommended workup for chronic fatigue should include assessment of nine key contributing factors: pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, alcohol/substance abuse, medication side effects, and comorbidities, followed by targeted interventions based on findings. 1

Initial Evaluation

Screening and Assessment

1. Fatigue Severity Rating:

   • Use a 0-10 numeric rating scale (0 = no fatigue, 10 = severe fatigue)
   • Mild (1-3): Requires education only
   • Moderate (4-6): Requires evaluation
   • Severe (7-10): Requires prompt evaluation 1

2. Focused History:

   • Pattern of fatigue: onset, duration, change over time
   • Alleviating and exacerbating factors
   • Impact on daily functioning and activities
   • Presence of post-exertional malaise (key symptom for ME/CFS) 2
   • Patient's understanding of their condition 3

3. Physical Examination:

   • Focus on cardiopulmonary, neurologic, and skin examinations 2
   • Assess for signs of underlying medical conditions

Laboratory Workup

• Complete blood count (anemia)
• Comprehensive metabolic panel (liver, kidney function)
• Thyroid-stimulating hormone (hypothyroidism)
• Urinalysis
• Inflammatory markers: ESR, CRP
• Iron studies
• Vitamin B12, folate, and vitamin D levels 1

Management Based on Etiology

1. Physiologic Fatigue

• Optimize sleep hygiene:
  • Regular sleep schedule
  • Comfortable sleep environment
  • Limit screen time before bed 1
• Balanced nutrition
• Energy conservation strategies:
  • Schedule activities during peak energy times
  • Delegate non-essential tasks
  • Use labor-saving devices 1

2. Secondary Fatigue (Due to Identifiable Causes)

• Treat specific underlying conditions:
  • Anemia: Iron supplementation
  • Hypothyroidism: Levothyroxine
  • Depression: SSRIs (fluoxetine, paroxetine, sertraline) 4
  • Sleep disorders: Appropriate sleep interventions 1
  • Medication side effects: Adjust dosing or change medications

3. Chronic Fatigue/ME/CFS

• Exercise Therapy:
  • For chronic fatigue without ME/CFS: Structured exercise program with gradual progression
  • For ME/CFS: Caution with exercise as it may trigger post-exertional malaise; focus on pacing activities 2
• Cognitive Behavioral Therapy:
  • Address catastrophic misinterpretation of symptoms
  • Develop self-monitoring techniques
  • Problem-solve current life difficulties 1, 3
• Pharmacologic Interventions:
  • Consider psychostimulants like methylphenidate after ruling out other causes 1
  • Caffeine or modafinil for episodic situations requiring alertness 4
  • SSRIs if depression is present 4

Follow-up and Monitoring

• Schedule regular follow-up visits rather than sporadic urgent appointments 4
• Reassess fatigue levels regularly to monitor progress
• Adjust interventions based on response
• Monitor for warning signs of excessive training load if exercise is part of treatment 1

Common Pitfalls to Avoid

• Attributing fatigue solely to one cause without comprehensive evaluation
• Overlooking psychological factors
• Dismissing fatigue as "normal" when it significantly impacts quality of life
• Prescribing exercise without proper assessment of underlying conditions 1
• Failing to recognize ME/CFS and the potential harm of exercise in these patients 2
• Repeating laboratory tests if initial results are normal (affects management in only 5% of patients) 4

By systematically evaluating and addressing the multiple factors that can contribute to chronic fatigue, clinicians can develop effective management strategies that improve patients' quality of life and functional status.