Fatigue

Aseem Utrankar

Background 

  • Obtain a thorough history and validate the pt's concerns 
  • Assess chronicity: acute <1 month, subacute 1-6 months, chronic >6 months 
  • Thorough review of systems, as well as questions regarding lifestyle (diet/exercise/sleep and any substance use) and social factors (financial/relationship stressors) 
  • Assess impact on daily life and accommodations the pt has made to cope 
  • Review medication list, age related cancer screening, prior lab values and imaging

Common Etiologies 

  • For otherwise well-appearing individual consider first screening for: 
    • Anemia, iron deficiency (even if anemia isn’t present) 
    • Liver/Kidney dysfunction 
    • Thyroid disease 
    • Mood disorder (anxiety, depression, adjustment disorder, substance use) 
    • Sleep Disorder (OSA, narcolepsy, REM sleep disorder, shift work disorder) 
  • If above screening is negative or patient is not well appearing, can also consider 
  • Cardiopulmonary: CHF, CAD/angina, PVD, obstructive lung disease 
  • Endocrine: Diabetes, adrenal insufficiency 
  • Hematologic/Neoplastic: occult malignancy 
  • Infectious: HIV, mononucleosis, hepatitis, TB, fungal, parasitic, long-covid 
  • Medication Use: opioids, benzodiazepines, antihistamines, muscle relaxants, antidepressants, beta-blockers, GABA analogues, substances 
  • Rheumatologic: fibromyalgia, PMR, SLE, RA, Sjögren's 
  • Neurologic: multiple sclerosis, myasthenia gravis

Evaluation 

  • Complete physical exam
  • Lab tests to order if >1 month duration:
    • Initial screening should include CMP, CBC w/ diff, iron studies, TSH
    • If not previously evaluated, can check HIV, hepatidities, A1c
  • Assess for mood disorder (PHQ-9, GAD7)
  • Assess for sleep disturbance (STOP-BANG, Epworth Sleepiness Scale) ± sleep study
  • Age appropriate cancer screening if applicable
  • Other considerations: family medical history, domestic violence, housing insecurity, substance use, new medications (OTC, supplements)

Management 

  • Treatment is largely specific to underlying etiology of fatigue (if found)
  • Etiology may never be identified; if undiagnosed for >6 mo, consider myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as a diagnosis of exclusion
  • Consider empiric trial of antidepressant (SSRI/SNRI/Bupropion) in those with residual/idiopathic fatigue and depressed mood – even if pt does not meet MDD criteria
  • Consider referral to long-COVID clinic if symptom timeline indicative of post-covid exposure
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