What is the recommended workup for a patient complaining of fatigue, joint pain, and tiredness without fever for a week?

Comprehensive Workup for Fatigue and Joint Pain

A comprehensive workup for a patient with fatigue, joint pain, and tiredness without fever for one week should include complete blood count, comprehensive metabolic panel, thyroid function tests, inflammatory markers, and autoimmune screening to rule out common causes of these symptoms.

Initial Laboratory Evaluation

The initial workup should include:

• Complete blood count (CBC) - to assess for anemia, infection, or malignancy 1
• Comprehensive metabolic panel (CMP) - to evaluate liver, kidney function, and electrolyte disturbances 1
• Thyroid-stimulating hormone (TSH) - to rule out hypothyroidism 1
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) - to assess for inflammation 1, 2
• Iron studies - including ferritin, iron, TIBC - to evaluate for iron deficiency 3, 1
• Vitamin B12, folate, and vitamin D levels - to identify nutritional deficiencies 1
• Urinalysis - to screen for renal disease or infection 1
• Antinuclear antibodies (ANA) - to screen for autoimmune disorders 3

Additional Testing Based on Joint Pain

For the joint pain component:

• Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies - to evaluate for rheumatoid arthritis 3, 4
• Uric acid level - to assess for gout if joint pain is severe or involves the first metatarsophalangeal joint 4
• Joint examination - to assess for swelling, tenderness, warmth, redness, and range of motion 3, 4

Imaging Considerations

• Plain radiographs of affected joints if symptoms persist beyond 2-3 weeks 3, 4
• Musculoskeletal ultrasound may be considered to detect early inflammatory changes if clinical suspicion for inflammatory arthritis is high 4

Assessing Fatigue Severity

Fatigue should be assessed using a standardized scale:

• 0: No fatigue
• 1-3: Mild fatigue
• 4-6: Moderate fatigue (requires evaluation)
• 7-10: Severe fatigue (requires prompt evaluation) 3, 1

Special Considerations

For Inflammatory Arthritis

If joint examination reveals inflammatory signs (swelling, warmth):

• Look for morning stiffness lasting >30 minutes
• Assess metacarpophalangeal and metatarsophalangeal joints with the "squeeze test" 3
• Consider early rheumatology referral, ideally within 6 weeks of symptom onset if inflammatory arthritis is suspected 3

For Fatigue Assessment

• Evaluate sleep patterns and quality
• Screen for depression and anxiety
• Assess pain levels, as pain is the dominating factor in fatigue experience 2
• Consider post-exertional malaise as a key symptom if fatigue worsens after physical or mental exertion 5

Common Pitfalls to Avoid

1. Attributing symptoms solely to one cause without comprehensive evaluation 1
2. Overlooking psychological factors that may contribute to fatigue 1
3. Dismissing fatigue as "normal" when it significantly impacts quality of life 1
4. Prescribing exercise without proper assessment of underlying conditions 1, 5
5. Failing to recognize that pain significantly contributes to fatigue in patients with joint pain 2

Management Approach

Management should be directed at underlying causes:

1. Treat identified conditions (anemia, hypothyroidism, vitamin deficiencies, etc.) 1

2. For joint pain without clear inflammatory signs:

   • NSAIDs (naproxen 500mg BID or meloxicam 7.5-15mg daily) for 4-6 weeks 3
   • If ineffective, consider prednisone 10-20mg daily for 2-4 weeks 3

3. For fatigue without identified organic cause:

   • Optimize sleep hygiene 1
   • Implement energy conservation strategies 1
   • Consider structured, gradual exercise program if no contraindications 1
   • Cognitive behavioral therapy for persistent fatigue 1, 6

4. Follow-up and monitoring:

   • Reassess in 2-4 weeks if symptoms persist
   • Consider specialty referral (rheumatology) if joint symptoms worsen or don't improve 3
   • Adjust treatment plan based on laboratory findings and response to initial management 1

Remember that fatigue and joint pain often represent a multisystem issue requiring careful evaluation of both physical and psychological factors to determine appropriate management.