General Medicine
Fatigue
#Fatigue
Intake
- Onset: ***
- Characteristics: ***
- Associated Symptoms: *** excessive daytime sleepiness, SOB/DOE, cough, chest pain, weight loss, decreased appetite, sleep issues, mood changes, hot/cold intolerance, changes in skin/hair, excessive thirst/urination, fevers,
- Sleep Hygiene: *** time to bed and to wake, the quantity of sleep, difficulty falling or staying asleep, nighttime awakenings, caffeine or EtOH use, snoring, apneic episodes
- Notable PMH: *** depression, CHF, COPD, ESRD, thyroid disease
- Medications: *** SSRI, TCAs, antihistamines, antipsychotics, beta-blockers, opioids, anticonvulsants
Plan
- Labs - CBC, CMP, TSH, iron studies, Vitamin B12, folate, ESR/CRP, creatine kinase (CK), urinalysis; HIV, HBV/HCV, monospot, cortisol, ANA/RF, lyme serologies
- PHQ-9
- Refer to sleep medicine for sleep studies
- Discuss the importance of healthy lifestyle choices - diet, regular exercise, sleep hygiene, stress management, avoiding substances
Differential
- Endocrine/Metabolic - hypothyroidism, diabetes, CKD, adrenal insufficiency
- Heme/Onc - anemia, leukemia, multiple myeloma, solid malignancy
- Infectious - EBV, HIV, hepatitis, chronic infections (TB)
- Cardiopulmonary - CHF, COPD, CAD, OSA
- Rheumatologic - fibromyalgia, SLE, RA, Sjogrens
- Psychiatric - depression, anxiety, somatization
- Neurologic - multiple sclerosis, Parkinsons, Myasthenia
- Nutritional - Vitamin D deficiency, iron deficiency, malnutrition
- Medications - sedatives, antidepressants, antipsychotics, antihistamines, opioids, substances
Template coming soon!
Patient Guidance and Information
Fatigue Guidance
Fatigue can have many causes, and we are working to identify a potential medical reason. Fatigue can sometimes by a symptom of an underlying medical condition. We have ordered some tests to help identify any potential causes.
Here are some general recommendations to help manage fatigue:
Lifestyle Changes: Regular physical activity and a balanced diet can have a significant impact on your energy levels. Try to incorporate moderate exercise into your routine and consume a diet rich in fruits, vegetables, lean proteins, and whole grains.
Sleep Hygiene: Ensure that you are getting adequate, quality sleep. Maintain a regular sleep schedule, create a relaxing bedtime routine, and make your sleep environment comfortable and free of distractions.
Stress Management: Chronic stress can lead to fatigue. Consider incorporating relaxation techniques such as deep breathing, yoga, or meditation into your routine.
Limit Alcohol and Caffeine: Excessive alcohol or caffeine can interfere with your sleep and energy levels.
Sleep Hygiene
Persistent sleep difficulties may be a sign of a sleep disorder that requires specialized treatment.
Good sleep hygiene is vital for overall health and wellbeing. Here are some recommendations to help improve your sleep habits:
Establish a Schedule: Try to go to bed and wake up at the same time every day, including on weekends. Consistency helps regulate your body's internal clock and could help you fall asleep and stay asleep throughout the night.
Create a Bedtime Routine: Establishing a pre-sleep routine can signal to your body that it's time to wind down and get ready for sleep. This could include activities such as reading a book, taking a warm bath, listening to soft music, or doing some relaxation exercises.
Make Your Sleep Environment Comfortable: Keep your bedroom quiet, dark, and cool. Consider using earplugs, an eye mask, or a white noise machine if necessary. Ensure your mattress and pillows are comfortable and supportive.
Limit Screen Time Before Bed: The light emitted by phones, tablets, computers, and TVs can interfere with your body's production of melatonin, a hormone that regulates sleep. Try to turn off these devices at least an hour before bedtime.
Be Mindful of Eating and Drinking: Avoid going to bed either hungry or overly full. Limit how much you drink before bed to prevent disruptive middle-of-the-night trips to the bathroom.
Limit Napping: Long daytime naps can interfere with nighttime sleep. If you choose to nap, limit yourself to about 20 to 30 minutes and make it during the mid-afternoon.
Physical Activity: Regular physical activity can help you fall asleep faster and enjoy deeper sleep. However, don't exercise too close to bedtime as it might interfere with your sleep.
Avoid Stimulants: Avoid beverages containing caffeine and alcohol close to bedtime. These substances can interfere with your ability to fall asleep and the quality of your sleep.
If You Remember Nothing Else
Fatigue is often multifactorial, so always consider a broad differential including endocrine disorders (such as hypothyroidism), hematologic conditions (like anemia), sleep disorders (such as sleep apnea), psychiatric illnesses (depression, anxiety), chronic infections, malignancies, and medication side effects. Your history and physical exam should guide your workup; be sure to ask about duration, pattern, and associated symptoms of fatigue, as well as sleep hygiene. Target your laboratory investigations based on your history. Initial tests often include CBC, CMP, TSH, and iron studies. Empower patients by discussing lifestyle modifications that can help with fatigue (adequate sleep, regular physical activity, balanced diet, and good hydration). Finally, always be alert to "red flag" symptoms such as significant weight loss, severe pain, or shortness of breath, which may indicate a more serious underlying condition requiring immediate attention.
Clinical Pearls
- Fatigue refers to a lack of energy and motivation whereas sleepiness refers to a propensity to fall asleep
- Results of laboratory studies affect management in only 5 percent of patients, and if initial results are normal, repeat testing is generally not indicated.
- Chronic fatigue syndrome is a diagnosis of exclusion that requires symptoms to be present for at least 6 months, is not relieved by rest, and significantly interfere with daily activities; most commonly seen in 40-60 year old women; the fatigue is often worsened by physical or mental exertion
- Fatigue can be a symptom of iron deficiency even in the abscense of anemia
- Radiation-induced fatigue can occur regardless of the site of irradiation; often a progressive fatigue that starts within a few weeks of starting therapy and worsens with cumulative radiation; believed to be caused by inflammatory response and cytokine release, as well as alterations in muscle and mitochondrial function, possibly worsened by marrow suppression leading to anemia; radiation is also a challenging process to undergo, and depressed mood likely plays a role
- Thoguh they can be sedating themselves, SSRIs may improve energy in patients with depression if the etiology of the fatigue is the mood disorder
Trials and Literature
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