How do you approach diagnosing and managing fatigue?

Approaching Fatigue: Systematic Evaluation and Management

Screen every patient for fatigue using a 0-10 numeric rating scale at initial and follow-up visits, with scores ≥4 triggering comprehensive evaluation for treatable causes, followed by targeted nonpharmacologic and pharmacologic interventions based on clinical context. 1

Initial Screening Phase

Use quantitative assessment immediately:

• Apply a 0-10 numeric rating scale (0 = no fatigue; 10 = worst fatigue) 1
• Classify severity: mild (1-3), moderate (4-6), severe (7-10) 1
• Scores ≥7 correlate with marked decreases in physical functioning 2
• Screen inpatients daily and outpatients at every routine visit 1

For mild fatigue (1-3):

• Provide education on fatigue management strategies 1
• Implement periodic rescreening 1

Focused Evaluation for Moderate-to-Severe Fatigue (≥4)

Conduct comprehensive history targeting:

• Onset, pattern, duration, and changes over time 2
• Interference with daily activities and physical functioning 2
• Associated symptoms: pain, sleep disturbances, mood changes, fever, bowel/bladder changes 2
• Medication review for offending agents 2

Identify treatable contributing factors systematically:

• Anemia: Check hemoglobin, iron studies, inflammatory markers 3
• Endocrine dysfunction: Assess thyroid function (TSH, free T4) 3
• Nutritional deficiencies: Evaluate vitamin D, magnesium, B12 levels 3
• Mood disorders: Screen for depression and anxiety 2
• Sleep disorders: Assess sleep quality and duration 2
• Pain syndromes: Evaluate adequacy of pain control 2
• Cardiac dysfunction: Consider if clinically indicated 3

Minimal laboratory investigation should include:

• Complete blood count with differential 4, 5
• Comprehensive metabolic panel 4
• Thyroid function tests 4
• Erythrocyte sedimentation rate or C-reactive protein 5
• Urinalysis 5

Critical caveat: Laboratory results affect management in only 5% of patients, and if initial results are normal, repeat testing is generally not indicated unless new symptoms develop 4

Treatment Algorithm Based on Findings

When Treatable Causes Are Identified

Address all reversible factors before additional interventions:

• Correct anemia with iron supplementation, erythropoietin, or transfusion as appropriate 1, 2
• Treat depression with SSRIs (fluoxetine, paroxetine, or sertraline) 4
• Manage anxiety disorders with appropriate therapy 2
• Optimize pain control 2
• Adjust or discontinue offending medications 2
• Treat thyroid dysfunction with levothyroxine 1
• Improve sleep hygiene 2

Reevaluate fatigue after treating identified factors 1

When No Treatable Causes Found or Fatigue Persists

Implement nonpharmacologic interventions (first-line):

• Exercise program: Structured, progressive aerobic exercise and stretching (e.g., walking) to improve functional capacity 1, 4
• Energy conservation strategies: Teach pacing techniques to maintain energy 1
• Psychosocial interventions: Cognitive behavioral therapy to manage stress and improve coping 1, 6
• Sleep interventions: Address sleep disturbances with behavioral modifications 1
• Nutritional counseling: Refer to dietitian for comprehensive assessment 2

Consider pharmacologic options (adjunctive):

• Methylphenidate: May provide benefit for short-term use 1
• Methylprednisolone: Consider for short-term use in advanced disease states 1
• Modafinil: Useful for episodic situations requiring alertness 4

Important warning: Exercise can be harmful in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) by triggering postexertional malaise; these patients require activity pacing instead 6

Context-Specific Management

Tailor interventions based on clinical status:

• Active treatment phase: Focus on managing treatment-related fatigue and optimizing supportive care 1
• Post-treatment phase: Continue monitoring as fatigue may persist despite remission 1
• End-of-life care: Prioritize comfort; nutritional interventions should not be forced 1

Interdisciplinary Referrals

Refer to specialists when appropriate:

• Physical therapy for exercise prescription and functional assessment 1, 3
• Dietitian for nutritional deficits 1, 2
• Mental health professionals for persistent mood disorders 1
• Sleep medicine for refractory sleep disturbances 1
• Symptom management service for complex cases 1

Ongoing Reevaluation

Establish iterative monitoring:

• Rescreen fatigue severity at each visit using the same 0-10 scale 1, 2
• Schedule regular follow-up visits rather than sporadic urgent appointments 4
• Pursue additional investigation if fatigue remains ≥4 after treating identified causes 2
• Monitor for new symptoms that may indicate evolving pathology 3, 2

Common Pitfalls to Avoid

• Failing to quantify fatigue severity leads to inadequate triage and treatment 1
• Extensive laboratory "fishing expeditions" when initial workup is normal waste resources without improving outcomes 4, 7
• Dismissing fatigue as purely psychological without systematic evaluation of organic causes 4, 7
• Prescribing exercise to patients with ME/CFS can worsen postexertional malaise 6
• Neglecting to reassess after interventions prevents optimization of management 1, 2
• Forcing nutritional interventions in terminal patients contradicts comfort-focused care 1