Workup and Management of Fatigue in a 67-Year-Old Patient in the Emergency Room
A comprehensive evaluation for fatigue in a 67-year-old patient presenting to the ER should include assessment of fatigue severity, focused laboratory testing, and screening for common contributing factors, with management directed at treating underlying causes.
Initial Assessment
Fatigue Severity Assessment
- Quantify fatigue using a 0-10 scale or categorize as none/mild/moderate/severe 1
- Scores 0-3: Mild fatigue (requires education only)
- Scores 4-6: Moderate fatigue (requires evaluation)
- Scores 7-10: Severe fatigue (requires prompt evaluation)
Focused History
- Onset, pattern, duration, and change over time of fatigue
- Associated symptoms (especially pain, pulmonary complaints, unintentional weight loss)
- Medication review (prescription and over-the-counter)
- Sleep patterns and disturbances
- Emotional distress assessment
- Cancer history or risk factors
Laboratory and Diagnostic Workup
First-Line Testing (Essential)
- Complete blood count with differential
- Comprehensive metabolic panel
- Thyroid-stimulating hormone (TSH)
- Urinalysis
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
Second-Line Testing (Based on Clinical Suspicion)
- Iron studies, vitamin B12, folate, and vitamin D levels
- Electrocardiogram if cardiac symptoms present
- Chest X-ray if pulmonary symptoms present
- Echocardiogram if history of cardiotoxic treatments
Common Causes to Consider
Medical Conditions
- Anemia
- Cardiac dysfunction
- Endocrine disorders (especially hypothyroidism)
- Renal dysfunction
- Pulmonary disease
- Malignancy (particularly important in this age group)
- Infection
Contributing Factors
- Sleep disturbances (insomnia, sleep apnea)
- Emotional distress (depression, anxiety)
- Medication side effects
- Nutritional deficiencies
- Deconditioning
Management Approach
Treatment of Underlying Conditions
- Address specific medical causes identified in workup
- Correct anemia, electrolyte imbalances, and nutritional deficiencies
- Optimize management of chronic conditions
Non-Pharmacological Interventions
- Physical activity: Structured exercise program combining moderate aerobic exercise and strength training 1
- Energy conservation strategies: Schedule activities during peak energy times
- Sleep hygiene improvement
- Cognitive behavioral therapy for persistent fatigue
Pharmacological Considerations
- Avoid prescribing medications specifically for fatigue without identified cause
- Consider psychostimulants only for episodic situations requiring alertness 2
- Selective serotonin reuptake inhibitors may be appropriate if depression is present
Special Considerations for the ER Setting
- Rule out life-threatening causes first (myocardial infarction, pulmonary embolism, sepsis)
- Assess for acute exacerbation of chronic conditions
- Determine if hospitalization is needed based on severity of underlying condition
- Arrange appropriate follow-up with primary care for continued management
Follow-up Planning
- Schedule regular follow-up visits rather than sporadic urgent appointments 2
- Reassess fatigue levels using the same standardized scale
- Adjust treatment plan based on response and new findings
Common Pitfalls to Avoid
- Attributing fatigue solely to age 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
Remember that fatigue is a complex symptom with diverse etiologies, and while serious pathology is uncommon, it requires systematic evaluation to identify treatable causes and improve patient outcomes.