How should I evaluate and manage fatigue in a 17-year-old female?

Evaluation and Management of Fatigue in a 17-Year-Old Female

Begin by quantifying fatigue severity using a 0-10 numeric rating scale, where scores of 4-10 indicate moderate-to-severe fatigue requiring comprehensive evaluation for treatable causes, while scores of 0-3 warrant only education and periodic rescreening. 1

Initial Screening and Severity Assessment

• Use a 0-10 numeric scale (0 = no fatigue, 10 = worst imaginable) to quantify severity 1
• Mild fatigue (1-3): Provide education about fatigue management and schedule periodic rescreening 1
• Moderate-to-severe fatigue (4-10): Proceed immediately to comprehensive focused evaluation 1, 2

Red Flag Symptoms Requiring Urgent Evaluation

Screen for red flags that indicate serious underlying pathology requiring immediate workup: 1, 2

• Fever or drenching night sweats 1, 2
• Unexplained weight loss or unintentional weight changes 1, 2
• New or worsening pain 2
• Pulmonary complaints or dyspnea 2
• Lymphadenopathy or hepatosplenomegaly 1, 2
• Neurological symptoms 2
• Concerning skin manifestations 2

If any red flags are present, extensive workup is mandatory to rule out malignancy, infection, or serious comorbidities. 1

Focused History for Moderate-to-Severe Fatigue

Document the following specific details: 3, 1

• Onset, pattern, and duration of fatigue 3
• Changes over time and temporal relationships 3
• Associated or alleviating factors 3
• Impact on daily functioning and school performance 2
• Interference with normal activities 1

Assessment of Treatable Contributing Factors

Medical Comorbidities to Evaluate:

• Anemia: Common in adolescent females due to menstruation 2
• Thyroid dysfunction: Hypothyroidism frequently causes fatigue 3, 2
• Cardiac dysfunction: Assess for palpitations, chest pain, exercise intolerance 2
• Sleep disturbances: Present in 30-75% of fatigued patients 2
• Pain: Frequently clusters with fatigue 2
• Emotional distress: Depression present in 25-33% of fatigued patients; anxiety also common 2

Medication and Substance Review:

• Document all prescription medications, over-the-counter drugs, herbal supplements, and vitamins 1, 2
• Identify fatigue-inducing medications: β-blockers, SSRIs, antihistamines, sleep aids 3, 1, 2
• Screen for alcohol or substance abuse, which aggravates sleep disturbance and fatigue 2

Nutritional and Activity Assessment:

• Document weight changes and calculate BMI 1
• Evaluate caloric intake changes and dietary patterns 3, 1
• Assess for nutritional deficiencies (vitamin B12, folate, vitamin D) 2
• Query about exercise patterns and functional status changes 1, 2
• Determine if deconditioning or decreased activity level is present 3, 2

Laboratory Workup for Moderate-to-Severe Fatigue (Scores 4-10)

Order the following initial screening tests: 1, 2

• Complete blood count with differential: Compare hemoglobin/hematocrit; assess all cell lines for anemia 3, 2
• Comprehensive metabolic panel: Evaluate electrolytes, hepatic and renal function 3, 2
• Thyroid-stimulating hormone (TSH): Screen for hypothyroidism 3, 2
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Detect inflammatory processes 1

Additional targeted testing based on clinical context: 2

• Vitamin B12, folate, vitamin D levels if nutritional deficiency suspected 2
• Pregnancy test in sexually active females
• Monospot or EBV titers if infectious mononucleosis suspected

Management Algorithm

Step 1: Address Identified Contributing Factors

• Correct anemia: Iron supplementation if iron deficiency identified 2
• Treat hypothyroidism: Thyroid hormone replacement if TSH elevated 2
• Manage depression/anxiety: Use validated screening tools (PHQ-9, GAD-7); consider SSRIs when appropriate 2
• Optimize sleep: Implement cognitive-behavioral therapy for insomnia; treat sleep apnea if present 2
• Address pain: Use evidence-based pain management strategies 2
• Correct nutritional deficiencies: Ensure adequate caloric intake and supplement as needed 2
• Review and adjust medications: Taper or discontinue fatigue-inducing agents when possible 2

Step 2: Universal Interventions for All Patients

Implement these interventions regardless of identified causes: 1, 2

• Structured physical activity program: Initiate graded exercise therapy with stretching plus aerobic activity (e.g., moderate walking) 1, 2
• Sleep hygiene optimization: Consistent bedtime, limit stimulants, create restful environment 2
• Energy conservation strategies: Balance activity, rest, and sleep 2
• Patient education: Explain the nature of fatigue, distinguish normal from pathologic fatigue, teach self-monitoring 2

Step 3: Specialist Referral When Indicated

Refer to appropriate specialists if: 3, 2

• Fatigue persists despite addressing modifiable factors 2
• Organ-specific dysfunction identified (cardiology, endocrinology) 3, 2
• Mental health concerns require specialized treatment 3, 2
• Sleep disorders need polysomnography 2

Follow-Up Strategy

• Schedule regular follow-up visits and rescreen with numeric rating scale 2
• Monitor symptom trajectory and response to interventions over time 2
• Continue screening even after improvement, as fatigue may recur 3

Critical Pitfalls to Avoid

• Do not attribute all symptoms to "normal adolescent fatigue" without thorough evaluation for treatable medical conditions 2
• Always consider medication side effects as potential contributors 2
• Remember that fatigue rarely occurs in isolation; it frequently clusters with pain, sleep disturbance, and emotional distress 2
• Do not overlook menstrual-related anemia in adolescent females, which is a highly treatable cause 2
• Screen for depression and anxiety systematically, as these are present in 25-33% of fatigued patients and often overlooked 2