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

Evaluation and Management of Chronic Fatigue

The recommended workup for chronic fatigue should include comprehensive laboratory testing for iron studies, thyroid function, vitamin deficiencies, inflammatory markers, and autoimmune indicators, followed by targeted management of identified causes or implementation of structured exercise programs, sleep hygiene optimization, and cognitive behavioral therapy for idiopathic fatigue. 1

Initial Evaluation

Laboratory Workup

• Complete blood count
• Comprehensive metabolic panel
• Thyroid-stimulating hormone
• Iron studies (ferritin, iron, TIBC)
• Vitamin B12 and folate levels
• Vitamin D level
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Antinuclear antibodies (ANA)
• Urinalysis 1

Fatigue Assessment

• Use standardized fatigue scale (0-10):
  • 0: No fatigue
  • 1-3: Mild fatigue (requires education only)
  • 4-6: Moderate fatigue (requires evaluation)
  • 7-10: Severe fatigue (requires prompt evaluation) 1

Detailed History

• Duration and pattern of fatigue
• Onset and progression
• Associated or alleviating factors
• Impact on daily functioning
• Sleep patterns
• Psychological factors (stress, anxiety, depression)
• Medication review
• Recent infections (including COVID-19 history) 1

Management Approach

Treating Underlying Causes

• Address specific conditions identified in workup:
  • Iron deficiency
  • Vitamin deficiencies
  • Thyroid dysfunction
  • Inflammatory conditions
  • Depression/anxiety 1, 2

Non-pharmacological Interventions

1. Structured Exercise Program

   • Combine aerobic and resistance exercises
   • Start with low intensity and gradually progress
   • Adjust based on fatigue severity 1

2. Sleep Hygiene Optimization

   • Regular sleep schedule
   • Limit daytime napping to short periods (20-30 minutes)
   • Avoid caffeine and alcohol before bedtime
   • Create comfortable sleep environment 1, 2

3. Energy Conservation Strategies

   • Schedule activities during peak energy times
   • Delegate non-essential tasks
   • Use labor-saving devices
   • Balance activity with rest 1

4. Cognitive Behavioral Therapy

   • Addresses negative thought patterns
   • Develops self-monitoring techniques
   • Implements stress management strategies 1, 3

Pharmacological Options

• For depression: Selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline) 1, 2
• For episodic situations requiring alertness: Caffeine or modafinil 1, 2
• For severe cases: Consider psychostimulants like methylphenidate after ruling out other causes 1, 4

Special Considerations

Chronic Fatigue Syndrome (CFS)

• Consider when fatigue persists >6 months with at least four of the following:
  • Postexertional malaise
  • Unrefreshing sleep
  • Impaired memory/concentration
  • Muscle pain
  • Polyarthralgia
  • Sore throat
  • Tender lymph nodes
  • New headaches 3
• Management focuses on:
  • Cognitive behavioral therapy
  • Graded exercise therapy 3

Post-COVID Syndrome

• Consider in patients with history of COVID-19 infection
• May present with persistent fatigue and brain fog 1

Follow-up and Monitoring

• Schedule regular follow-up visits rather than sporadic urgent appointments 2
• Reassess fatigue levels regularly
• Monitor for warning signs of excessive training load
• Adjust treatment plan based on response 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
• Failing to recognize medication side effects as potential causes of fatigue 1
• Excessive laboratory testing after initial normal results 2