What are the next steps in managing a 23-year-old patient with chronic fatigue, normal blood results, good mental health, and no other symptoms, who has a normal body mass index (BMI), no limitations of daily activities, and follows a healthy diet?

Management of Chronic Fatigue in a 23-Year-Old Patient

For a 23-year-old patient with chronic fatigue, normal blood results, good mental health, and no other symptoms, a comprehensive evaluation of treatable contributing factors followed by targeted interventions including physical activity and psychosocial support is recommended.

Initial Assessment and Screening

• Use a numeric rating scale (0-10) to quantify fatigue severity, with 0-3 considered mild, 4-6 moderate, and 7-10 severe 1, 2
• Conduct a focused fatigue history including onset, pattern, duration, and changes over time 1, 2
• Assess for associated or alleviating factors that may contribute to fatigue 1
• Evaluate interference with normal functioning and daily activities 2

Comprehensive Evaluation of Treatable Contributing Factors

• Assess for comorbidities that may contribute to fatigue, including:

  • Endocrine dysfunction (thyroid disorders, adrenal insufficiency) 1
  • Anemia or iron deficiency (even with normal hemoglobin) 1
  • Sleep disturbances including sleep apnea 1
  • Nutritional deficiencies (vitamin D, magnesium) 1
  • Emotional distress (depression, anxiety) 1

• Consider laboratory evaluation based on clinical presentation:

  • Complete blood count with differential 1
  • Comprehensive metabolic panel 1
  • Thyroid function tests 1
  • Iron studies (ferritin, transferrin saturation) 1
  • Vitamin D levels 1
  • Inflammatory markers (ESR, CRP) 1

Management Interventions

Physical Activity (First-Line)

• Implement a structured exercise program, starting with low-intensity activities and gradually increasing 1
• Activity enhancement is a category 1 recommendation for managing fatigue 1
• Even a moderate walking exercise program can improve energy levels and decrease fatigue 1
• Consider referral to a physical therapist for a personalized exercise prescription if deconditioning is significant 1

Psychosocial Interventions

• Offer cognitive behavioral therapy (CBT), which has shown effectiveness in reducing fatigue (category 1 recommendation) 1
• Consider mindfulness-based therapy, which has demonstrated moderate improvements in quality of life 1
• Provide education about fatigue management strategies and self-monitoring techniques 1
• Supportive expressive therapy, including support groups and counseling, may be beneficial 1

Nutritional Support

• Evaluate nutritional intake and provide guidance on a balanced diet 1
• Address any identified nutritional deficiencies, particularly iron, vitamin D, and magnesium 1
• Consider consultation with a nutrition expert if substantial abnormalities are found 1

Sleep Hygiene

• Assess sleep patterns and provide education on improving sleep quality 1
• Address any identified sleep disturbances that may be contributing to fatigue 1
• Consider referral for sleep study if sleep apnea is suspected 1

Special Considerations

• Avoid medications that may worsen fatigue, including certain sleep aids, pain medications, or antiemetics 1
• For persistent fatigue despite initial interventions, consider evaluation for chronic fatigue syndrome (CFS) 3, 4
• Avoid stimulants for fatigue symptoms in patients with chronic multisymptom illness 1
• Be aware that fatigue rarely occurs in isolation and often clusters with other symptoms that may not be immediately apparent 2

Follow-Up and Monitoring

• Reassess fatigue levels regularly using the same rating scale to track progress 1, 2
• Adjust interventions based on response to treatment 1
• Consider referral to specialists if fatigue persists despite appropriate interventions 1