Question

In your clinical setting, you will encounter many patients with the complaints of fatigue. What would you include in a work-up of a 25-year-old female that comes to your office, with the complaint of increasing fatigue, over the last few months?

Include history, physical exam, labs, diagnostics, and your differential diagnosis and management.

Answer 1

Fatigue can be physical or mental. It is a feeling of extreme weakness, lack of motivation and energy. Patients often describe fatigue as tiredness, inability to perform any task. Fatigue is a normal response of the body towards intensity of the activity. But the fatigue resulting due to increased activity will be relieved within hours or a day after the activity is withdrawn. Fatigue is not a disease, it is a symptom which has a gradual onset. Many diseases precipitate fatigue as one of the symptoms which may be physical or psychological. The patient may not identify it as a abnormal symptoms unless its compared with once ability to complete task at a time. Some may also identify fatigue as a cause of aging and may ignore the symptom.

History taking:

The health history have a crucial role in identifying the the fatigue is normal or its an abnormal symptom. The history should include the time of day when fatigue occurs the most and which factor precipitate fatigue. The activity pattern of the patient needs to be questioned and their capacity to sustain normal activity. History should also include their

• activity management
• dietary habits,
• medication history,
• history of travel to remote areas,
• sleep pattern,
• substance abuse like smoking or alcohol
• any event of grief or unexpected life events of loss, depression
• weight changes
• Menstrual history
• presence of any other medical ailments or surgical history in past.
• Elimination process including vomiting or diarrhea
• fever and chills, muscle pain
• chest pain, shortness of breath

Physical examination:

The physical examination will require a head to foot examination of the patient. This will require all the four elements of physical examination i.e inspection, auscultation, percussion and palpation. Inspection of the colour of eyes,hair,skin, nails, body gait and posture, presence of any marks, cuts or wounds. Ausultation involves heart sounds, bowel sounds. Percussion involves evaluation of presence of fluid accumulation by resonance and dullness. Palpation will involve estimation of organ margins, presence of nodes or lumps. Along with this pelvic examination as she is a female is also to be done.

Laboratory and diagnostic test: Complete blood count including the renal function test, liver function test, thyroid function test, Test for deficiencies in vitamins, CPK and ESR, Blood glucose,urine test for pregnancy, ECG and chest xray to rule out any cardiac or pulmonary anomely, Ultrasound to evaluate the abdominal findings.

If any abnormality is found in the initial screening and suggested test then further higher studies like echocardiology, CT scan, MRI and biopsy may be required.

Differential diagnosis:

• Insomnia disorder
• Iron deficiency anemia
• Depression
• Thyroid diseases
• Renal failure
• Liver disorders
• Chronic heart disease
• Chronic lung disease
• Neuromuscular disorder
• cancer
• Chronic infections.

Mangaement:

As the fatigue is a symptom, treating the underlying cause of the symptom is the best option. Some treatment for conditions of fatigue include

• Iron suppliments for anemia
• Medications and machines to reduce sleep apnea
• Medications to control blood sugar
• Antibitics to treat infections
• Medication to regulate thyroid functions
• Vitamin suppliments
• Dietary modifications and exercise regulation
• Stress management and relaxation techniques.
• Cessation of smoking, substance abuse
• Sex education.