Evaluation of Fatigue

Julie Blaszczak, MD
October 4, 2019
I have no disclosures
  Define classifications of fatigue
 Describe possible etiologies of fatigue and discuss common
diagnoses

Objectives  List relevant and high-yield aspects of the history and physical
examination to obtain for an individual presenting with fatigue
 Demonstrate critical thinking skills in regards to ordering lab work
for the evaluation of fatigue
 Review management of fatigue
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28yo F with no significant PMH presents with a
chief complaint of fatigue
Resources

Canada1 Australia2
Resources

USA3 UK4
Why is this  5-7% of primary care visits have primary complaint of fatigue2,4,8
 22-33% seeking care in primary care describe fatigue as
important? “important problem”3,5
  Chronicity1,5
 Acute: Less than one month
 Subacute or Prolonged: One to six months
 Chronic: Greater than six months
Classification  Etiology3
 Secondary: Underlying medical condition
 Physiologic: Imbalance in exercise, sleep, or diet not caused by an
underlying medical condition and relieved with rest
 Chronic: Greater than six months and not relieved with rest
 5
Classification:
Myalgic Encephalomyelitis/
Chronic Fatigue
Syndrome5,6
  Reduction or impairment in ability to engage in pre-illness levels
of activities for greater than six months and is accompanied by
fatigue that is not substantially alleviated by rest

Classification:  Post-exertional malaise

Myalgic Encephalomyelitis/  Unrefreshing sleep
Chronic Fatigue AND
Syndrome5,6
 Cognitive impairment
OR
 Orthostatic intolerance
5
1
3
  Difficult to determine exact rates of diagnoses2
 Common: stress/anxiety/depression, viral illnesses, sleep-related
Diagnosis disorders1,2,3,4
 No etiology found in about one third to one half of patients
(eventually become “symptom” diagnosis)1-5
  Study in CMAJ in 20097:
 Evaluated diagnoses established within one year after presentation
with fatigue in primary care
 Main diagnostic categories were musculoskeletal (19.4%) and
Diagnosis psychological problems (16.5%)
 Only 8.2% were diagnosed with somatic pathology at 12 month
follow-up
 Half did not receive any diagnosis that could explain their fatigue
  Study in BMC Family Practice in 20168:
 Systematic review that looked at 26 studies that investigated
underlying causes of “tiredness” in primary care
Diagnosis  Most common was depression at 18.5%
 Serious somatic diseases occurred at 3.1%
 Approximately same prevalence as non-fatigued patients
 Less than 2% of the patients were diagnosed with CFS
  History
How do we  Physical Examination
approach this?  Laboratory Work-up

*Above subsections are summarized from references 1-5, 10

Take a few minutes and discuss how you go
about evaluating fatigue in a 15-20 minute
office visit
  History
How do we  Physical Examination
approach this?  Laboratory Work-up
  Details regarding the fatigue
 Ask the patient to describe it in narrative
 Mental vs. physical
 Sleepiness vs. fatigue
History  Onset
 Recovery period
 Typical level of activity vs current level of activity (impact on QOL)
 Brief Fatigue Inventory5
  Medications associated with fatigue
 Antihistamines
 Corticosteroids
 Neuroleptics
History  Antiarrhythmics
 Antidepressants
 Antihypertensives (beta-blockers)
 Opioids
 Muscle relaxants
  Assess for mood disorder
 PHQ9 and GAD7

 Assess for sleep disorder

 Assess both quality and quantity
History  Epworth Sleepiness Scale
 STOP-BANG
 Sleep Disorders Questionnaire
 Assess for substance use and IPV
  Red Flags
 Previously well older patient with acute onset
 Weight loss
 Bleeding
History  Shortness of breath or chest pain
 Lymphadenopathy
 Fever or other signs of infection
 Focal neurological deficits
 Onset of joint pain or other signs of inflammation
History  Make sure cancer screening is up to date
  History
How do we  Physical Examination
approach this?  Laboratory Work-up
  Vital signs
 Lymphadenopathy
 Cardiac murmurs
Physical  Thyroid nodules or goiter
Examination  Edema
 Joint swelling or rash
 Focal neurological finding
 Pale or jaundiced skin
  History
How do we  Physical Examination
approach this?  Laboratory Work-up
  Most guidelines and recommendations state that you should
assess basic lab work if symptoms are present for longer than one
Laboratory month without localized findings2,4,5,9
 If localized findings or concerning symptoms, order as
Work-up appropriate

 Results affect management of about 5% of patients2,3,7

  Results of the VAMPIRE Trial suggest that a limited set of blood
tests is as useful as more extensive testing9
Laboratory  Hemoglobin

Work-up 

ESR
Glucose
 TSH

*Low re-consultation rates after 4 weeks and no large difference in

diagnoses or results of bloodwork in postponement group
(Recommendation of Dutch College of General Practitioners)
 3

Laboratory
Work-up: AFP
  CBC
 CMP
Laboratory  TSH

Work-up: UTD5  CK (if muscle pain or weakness present)

 Hepatitis C Ab (if risk factors present)
 HIV (if never tested or risk factors present)
 1

Laboratory Work-
up: CMAJ
  Initial tests, if appropriate (new onset)
 Urinalysis
 Blood glucose level
 If fatigue persists for four weeks (prolonged) or localized/red flag
symptoms
Laboratory Work-  CBC
up: Australia2  Electrolytes, urea, creatinine
 LFT
 ESR/CRP
 BGL
 TSH
 Ferritin
 2

Laboratory Work-
up: Australia
  CBC
 ESR
Laboratory Work-
 TSH
up: BMJ4
 Test for celiac (National Institute for Health and Clinical
Excellence)
What does this change, if anything, about
your practice?
  Treat underlying condition (if found…)
 Iron for iron deficiency anemia
 CPAP for OSA
 Therapy and/or antidepressants for depression
Sleep hygiene for insomnia
Management1-5, 10

 On and on…

 Cognitive behavioral therapy

 Exercise therapy
 Treatment with antidepressants if depressive symptoms present
 1. Cornuz, J, Guessous, I, & Favrat, B. (2006). Fatigue: a practical approach to
diagnosis in primary care. CMAJ, 174(6), 765-767.
2. Wilson, J, Morgan, S, Magin, P, & van Driel, M. (2014). Fatigue – a rational approach
to investigation. Australian Family Physician, 43(7), 457-461.
3. Rosenthal, T, Majeroni, B, Pretorius, R, & Malik, K. (2008). Fatigue: An Overview.
American Family Physician, 78(10), 1173-1179.
4. Hamilton, W, Watson, J, & Round, A. (2010). Investigating fatigue in primary care.
British Medical Journal, 341, 502-504.
5. Approach to the adult patient with fatigue. Up to Date. Retrieved on September
16, 2019.

References 6. Institute of Medicine. (2015). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

(ME/CFS): Key Facts. National Academy of Sciences: Washington, DC.
7. Nijrolder, I, van der Windt, D, de Vries, H, & van der Horst, H. (2010). Diagnoses
during follow-up of patients presenting with fatigue in primary care. CMAJ, 181(10),
683-687.
8. Stadje, R et al. (2016). The differential diagnosis of tiredness: a systematic review.
BMC Family Practice, 17, DOI 10.1186/s12875-016-0545-5.
9. Koch, H et al. (2009). Ordering blood tests for patients with unexplained fatigue in
general practice: what does it yield? British Journal of General Practice, 59(561), e93-
100.
10. Yancey, J & Thomas, S. (2012). Chronic Fatigue Syndrome: Diagnosis and
Treatment. American Family Physician, 86(8), 741-746.
Questions?