Fatigue

Meg Hayes

Fatigue is both a normal human response as well as a symptom of physical or psychological disease. It is a subjective sensation that is multicausal and nonspecific for which no one definition is universally accepted, nor can it be quantified or diagnosed with laboratory or imaging studies. Fatigue is the seventh most common symptom in primary care, accounting for more than 10 million office visits every year (1). Women present for medical care with fatigue more often than men, although it is not clear that a gender prevalence exists in the population. Among the large number of patients who seek primary medical care for the symptom of chronic fatigue, only 2% to 5% are found to have an organic disorder, and a similar number meets the criteria for chronic fatigue syndrome (CFS). The most common underlying cause of fatigue is an affective disorder, either depression or somatic anxiety (Chapters 3.1 and 3.3). In many cases, no medical diagnosis can be made and demands of work and social responsibilities seem to be the cause of fatigue (2).

Approach

A. Onset and chronicity. The complaint of fatigue should first be approached in terms of onset and chronicity as a means of further differentiating the cause from among physical (e.g., hypothyroidism), psychogenic (e.g., depression), physiologic (e.g., overwork), or a combination of those factors. The recent onset of fatigue, less than 1 month in duration and becoming worse, is more likely to be caused by physical illness. Chronic fatigue, greater than 6 months duration, is more likely to have a psychogenic or multifactorial cause. In a case of chronic fatigue for which diagnosis is elusive, the criteria for chronic fatigue syndrome should be considered.

B. Patient–physician communication. Communication between the physician and patient is key to successful management. Establishing rapport, demonstrating a flexible approach and personal concern with the aim of cultivating a respectful and therapeutic relationship, can lead to an appropriate and mutually satisfactory set of expectations for the pace of evaluation and treatment. It is important to elicit the patient’s diagnostic beliefs, as many attribute the fatigue to an organic medical disorder, and, therefore, resist psychiatric diagnosis or even questions that probe into that realm (3).

History

A thorough medical, social, and family history must be conducted to identify comorbid or contributing conditions that require treatment or suggest lifestyle modification.

A. The fatigue should be assessed in terms of duration, onset, level of impairment, and character. Specifically, fatigue should be distinguished from weakness and hypersomnolence.

B. A complete review of systems may point to a cardiovascular, neurologic, psychiatric, infectious, autoimmune, hematologic, pulmonary, endocrine, or malignant cause to pursue.

 C. Attention should also be given to medication—both prescription and over-the-counter—and to diet, exercise, substance abuse, and sleep disturbance.

 D. Lifestyle issues to explore include caretaking for young children, an elderly or ill relative, and the number of hours worked outside the home. Life stresses or major family transitions such as relocation, death, divorce, financial difficulties and past or current abuse or trauma should also be assessed.

Physical examination

A thorough physical examination should be done to investigate findings of underlying disease. This is also an important prerequisite to satisfy the patient’s concern regarding the possibility of an organic cause if a psychiatric diagnosis is made. Particular attention should be given to the presence of pallor, cardiac arrhythmia, dyspnea, fever or other indication of infection; weight loss; lymphadenopathy; evidence of inflammatory arthritis, occult blood loss, organomegaly, or abdominal masses; neurologic signs of impaired coordination; hypertension; edema; generalized pruritus; obesity; peripheral neuropathy; goiter; dry hair or skin; hemoptysis; or pregnancy. Conduct a mental status examination to identify abnormalities in mood, intellectual function, memory, and personality. Pay special attention to assessment of symptoms of depression or anxiety, suicidal ideation, and psychomotor retardation.

Testing.

 If diagnostic or patient concerns remain following the history and physical examination, a minimum battery of laboratory screening tests should be performed in the evaluation of fatigue. This should include a complete blood count with leukocyte differential, serum levels of alanine aminotransferase, total protein, albumin, globulin, alkaline phosphatase, calcium, phosphorus, glucose, blood urea nitrogen, creatinine, electrolytes, thyroid-stimulating hormone, erythrocyte sedimentation rate, and urinalysis. The choice of any further investigations should be guided by clinical assessment of the patient to confirm or exclude other causative possibilities; for example, obtain a chest x-ray study in the case of exposure to tuberculosis or a magnetic resonance imaging study of the brain if multiple sclerosis is suspected. In such cases, further investigation should be conducted according to accepted clinical standards. In particular, the use of other screening tests to diagnose CFS is not recommended in the clinical setting, but should be reserved for investigation in the setting of protocol-based research (4).

Diagnostic assessment

 A. Organic and psychogenic causes. If the evaluation through history, physical examination, and laboratory studies reveals an organic or psychogenic cause, the diagnosis of “fatigue” should be replaced with a more precise etiologic diagnosis. The most common biomedical causes of fatigue are psychogenic (57%), usually depression or anxiety, and organic causes (37%) with infection representing the largest subgroup followed by cardiovascular and endocrine abnormalities. Cases of cancer and connective tissue disease first presenting as fatigue are rare at 1% each (5). In the case that environmental factors are identified that contribute to fatigue, a trial of behavior modification may eliminate the complaint. Prolonged fatigue is defined as self-reported, persistent fatigue lasting 1 month or longer.

 B. Chronic fatigue syndrome. A diagnosis of CFS is made by two criteria:
(a) severe chronic fatigue of 6 months or longer duration with other known medical conditions excluded by clinical diagnosis; and (b) concurrent presence of four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain, multiple joint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep and postexertional malaise lasting more than 24 hours. The conditions must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue (4). For fatigue of undetermined cause present for 6 or more months that does not meet criteria for CFS, a diagnosis of idiopathic chronic fatigue is made.

References

1. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB. Chronic fatigue in primary care: prevalence, patient characteristics, and outcome. JAMA 1988;
260(7):929–934.

2. Komaroff AL, Buchwal DS. Chronic fatigue syndrome: an update. Annu Rev Med 1998;49:1–13.

3. Godwin M, Delva D, Miller K, et al. Investigating fatigue of less than six month’s duration. Guidelines for family physicians. Can Fam Physician 1999;45:373–379.

4. Fukuda K, Strauss S, Hickie I, Sharpe MC, Dobbins JG, Komaroff AL, and the International Chronic Fatigue Syndrome Study Group. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;
121:953–959.

5. Valdini AF. Fatigue of unknown etiology—a review. Fam Pract 1985;2(1):48–53.

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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