What should be included in the workup for a 51-year-old female with a 3-month history of fatigue?

Workup for a 51-Year-Old Female with 3-Month History of Fatigue

For a 51-year-old female with a 3-month history of fatigue, the workup should include a focused evaluation with complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, assessment of treatable contributing factors, and consideration of underlying medical conditions. 1

Initial Assessment

1. Quantify fatigue severity using a standardized 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

2. Focused history and physical examination for moderate to severe fatigue (score ≥4):

   • Assess onset, pattern, duration, change over time
   • Identify associated or alleviating factors
   • Evaluate interference with daily functioning 2

Laboratory Testing

Essential laboratory tests:

• Complete blood count (to assess for anemia)
• Comprehensive metabolic panel
• Thyroid-stimulating hormone (TSH) 1

Additional testing based on clinical suspicion:

• For cardiac symptoms: Consider ECG and echocardiogram
• For respiratory symptoms: Consider chest X-ray and pulmonary function tests 1

Assessment of Treatable Contributing Factors

Evaluate these 9 key factors that commonly cause fatigue:

1. Pain - Often clusters with fatigue
2. Emotional distress - Depression occurs in up to 33% of fatigued patients
3. Sleep disturbance - Present in 30-75% of patients with fatigue
4. Anemia - Common and treatable cause
5. Nutritional status - Assess caloric intake and electrolyte balance
6. Activity level - Both under and over-activity can contribute
7. Alcohol/substance use - Can exacerbate fatigue
8. Medication side effects - Particularly those causing sedation
9. Comorbidities - Identify underlying medical conditions 2, 1

Special Considerations

• Duration assessment: If fatigue has persisted >6 months with post-exertional malaise, consider myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) using the 2015 National Academy of Medicine diagnostic criteria 1, 3

• Psychological evaluation: Use standardized tools to screen for depression and anxiety, as these conditions frequently co-occur with fatigue 2, 1

• Review of systems: Pay particular attention to cardiopulmonary, neurologic, and skin examinations to help guide diagnosis 3

Common Pitfalls to Avoid

1. Don't attribute fatigue solely to one cause without comprehensive evaluation
2. Don't overlook psychological factors as potential contributors
3. Don't dismiss fatigue as "normal" when it significantly impacts quality of life
4. Don't prescribe exercise without proper assessment of underlying conditions
5. Don't fail to recognize medication side effects as potential causes 1

Follow-up Recommendations

• Schedule regular follow-up visits rather than sporadic urgent appointments
• Reassess fatigue levels using standardized scales
• Adjust treatment plan based on response 1, 4

Research shows that most diagnoses explaining fatigue are not made during the initial consultation, and only 8.2% of patients are diagnosed with clear somatic pathology 5. Therefore, a systematic approach with appropriate follow-up is essential for effective management.