What is the most appropriate physical exam for a patient presenting with fatigue?

Physical Examination for Fatigue

The most appropriate physical examination for a patient presenting with fatigue should focus on identifying the 9 key contributing factors: pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, alcohol/substance abuse, medication side effects, and comorbidities. 1

Initial Assessment

• Use a numeric rating scale (0-10) to quantify fatigue severity:
  • 0-3: Mild fatigue
  • 4-10: Moderate to severe fatigue (requires more focused evaluation)
  • ≥7: Associated with marked decrease in physical functioning 1, 2

Focused Physical Examination Components

Cardiovascular Assessment

• Vital signs (heart rate, blood pressure, respiratory rate)
• Heart sounds (murmurs, gallops, irregular rhythms)
• Peripheral pulses and edema
• Jugular venous distention
• Signs of anemia (pallor, tachycardia) 2

Respiratory Assessment

• Respiratory effort
• Lung sounds
• Signs of sleep apnea (obesity, large neck circumference) 1

Neurological Assessment

• Mental status
• Muscle strength and tone
• Deep tendon reflexes
• Gait and balance
• Signs of depression or anxiety 1

Endocrine Assessment

• Thyroid examination (enlargement, nodules)
• Signs of adrenal dysfunction (postural hypotension, skin pigmentation)
• Signs of diabetes (acanthosis nigricans) 2

Gastrointestinal Assessment

• Abdominal examination
• Nutritional status evaluation (weight changes, muscle wasting)
• Signs of malabsorption 2

Musculoskeletal Assessment

• Joint examination
• Muscle strength and bulk
• Signs of deconditioning 3

Assessment of Key Contributing Factors

1. Pain Assessment:

   • Location, intensity, pattern, and impact on function 1

2. Emotional Distress Screening:

   • Signs of depression or anxiety
   • Use validated screening tools (Beck Depression Inventory, CES-D, GDS, or Hamilton Depression Scale) 1

3. Sleep Disturbance Evaluation:

   • Sleep patterns, quality, and duration
   • Signs of sleep apnea or insomnia 1

4. Anemia Assessment:

   • Pallor of conjunctiva, nail beds, and palmar creases
   • Tachycardia or flow murmur 1, 2

5. Nutritional Assessment:

   • Weight changes (gain or loss)
   • Body mass index
   • Muscle wasting
   • Signs of vitamin deficiencies 1, 2

6. Activity Level Assessment:

   • Current exercise capacity
   • Changes in exercise patterns
   • Signs of deconditioning 1

7. Substance Use Assessment:

   • Signs of alcohol or drug use/abuse 1

8. Medication Review:

   • Identify medications with sedating side effects
   • Look for signs of medication side effects 1, 2

9. Comorbidity Assessment:

   • Signs of cardiac, pulmonary, renal, hepatic, or endocrine disease
   • Evidence of malignancy (lymphadenopathy, organomegaly) 1, 2

Special Considerations

• For patients with post-exertional malaise, assess for signs of myalgic encephalomyelitis/chronic fatigue syndrome 4
• In cancer patients or survivors, pay particular attention to signs of disease recurrence or treatment effects 1
• In stroke survivors, carefully assess for depression, which occurs in 18-68% of patients 1

Pitfalls and Caveats

• Physical examination alone has a low diagnostic yield (only about 2% of cases) for determining the cause of fatigue 5
• Normal physical examination findings do not exclude fatigue-causing conditions 2
• Avoid excessive testing when initial laboratory results are normal, as repeat testing rarely changes management 6
• Do not overlook medication side effects as a common cause of fatigue 1, 2
• Be aware that fatigue rarely occurs in isolation and commonly clusters with sleep disturbance, emotional distress, or pain 1

By systematically examining these areas, clinicians can identify potential causes of fatigue and develop appropriate treatment strategies to improve patient outcomes and quality of life.