Key Feature 4: Avoid early, routine investigations in patients with fatigue unless specific indications for such investigations are present.
Key Feature 5: Given patients with fatigue in whom other underlying disorders have been ruled out, assist them to place, in a therapeutic sense, the role of their life circumstances in their fatigue.
Skill: Patient Centered, Communication
Key Feature 6: In patients whose fatigue has become chronic, manage supportively, while remaining vigilant for new diseases and illnesses.
Skill: Patient Centered, Clinical Reasoning
Phase: Hypothesis generation, Treatment
Multiple Medical Problems
Key Feature 6: In patients with multiple medical problems and recurrent visits for unchanging symptoms, set limits for consultations when appropriate (ex: limit the duration and frequency of visits).
Skill: Patient Centered, Professionalism
Phase: Treatment, Follow-up
Today I saw two very different patients for a primary complaint of fatigue. The first was a man approaching 90 years of age who had an exhaustive list of chronic comorbidities, while the other was a middle-aged man who was fit and without any pre-existing medical issues. The differential for fatigue is massive, and requires an approach that fits the individual. For the 90 year-old gentleman, presumably with fatigue of a multifactorial nature secondary to significant advanced illness, performing an intensive search for a new cause would be much less likely to result in a cure for the fatigue than addressing his chronic disease progression. He had good reason to be experiencing what he characterized as a gradually worsening fatigue given what was already known. On the other hand, the spry 50 year-old had developed a new complaint of fatigue over the past month, without any evidence of any underlying culprit. I requested no new investigations of the 90 year-old gentleman, while I requested some basic bloodwork to screen for an underlying cause of fatigue in the 50 year-old man (given that he didn't have any localizing symptoms to tip me to look for any specific causes). This man also did not have any diagnosed psychiatric illness, and he took no medications and only occasionally drank alcohol. His sleep was pretty ordinary, and he was not experiencing any significant life stressors at home or at work. All other reasons for developing fatigue.
According to the UpToDate article, "Approach to the adult patient with fatigue," "Fatigue caused by an underlying medical or psychological condition usually presents as one of several reported symptoms. A specific etiology for fatigue is found less often when it is the principal or only complaint." That being said, it may be more likely than not that the bloodwork results for the otherwise healthy man comes back positive. If he returns to clinic to follow-up, which I advised him to do, then I would plan to delve a bit deeper into the possible psychosocial circumstances that may be contributing to this common symptom of general distress. How he may react in such a circumstance is as much my best guess as yours. Some people are very open-minded when it comes to the possibility of psychosocial circumstances affecting how one physically feels, while others negate against it like their life depends on it. In these circumstances, it is important to focus on building rapport and empathising with their perspective. After all, they may be feeling so crappy that it is hard to believe there is no underlying physical cause. But that is not true either. After all, there is no diagnostic testing to prove that patients with migraines feel pain, but we know it is fact, and there can be both physical and stress-related triggers for why they precipitate. This is not unlike chronic unexplained fatigue. There are many things that medicine does not have a test or a cure for. That being said, there is always a place for a relationship that can be therapeutic, in which patients are heard, understood, and cared for if only at the very least and very most by compassionate listening. It is important to provide supportive care for patients with chronic medical symptoms affecting quality of life, while at the same time setting limits on how frequently some patients return to clinic when symptoms are no longer changing despite best medical efforts.
Key Feature 2: Ask about other constitutional symptoms as part of a systematic approach to rule out underlying medical causes in all patients complaining of fatigue.
Skill: Clinical Reasoning
Per my previous post, my DDx for fatigue (adapted from the LMCC Objectives) includes pharmacologic side effects, (very) general medical disease, and idiopathic aetiologies. At least 3 of the 7 general medical disease categories (namely infectious, neoplastic-malignant, and connective tissue disorders) may include aetiologies that have fatigue along with other constitutional symptoms such as fevers, chills, night sweats, unintentional weight loss, and general malaise.
Neither of the patients I saw today who were concerned about fatigue (see previous post) endorsed constitutional symptoms associated with their fatigue. This one question meant that no infectious, malignant, or connective tissue disease workup was therefore warranted (at least not without other suggestive clinical signs and symptoms).
Key Feature 1: In all patients complaining of fatigue, include depression in the differential diagnosis.
Skill: Clinical reasoning
Phase: Hypothesis generation
Key Feature 3: Exclude adverse effects of medication as the cause in all patients complaining of fatigue.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis
A 39 year old female presented to clinic today for a breast lump. On review of systems, she noted feeling fatigued for 4-6 months or so. Later in the day, a 51 year old male presented for a periodic health examination and noted being more fatigued than before, also for many months.
My DDx (per LMCC Objectives) for a complaint of fatigue is as follows:
What kind of DDx has multiple organ systems as a single item on the differential? Fatigue is a hell of a presenting complaint.
On review of my patients' systems, they both described that their mood was lower in the past few months than it usually has been. But is this a chicken or egg? While both patients endorsed an associated psychiatric symptom, low mood can also be secondary to underlying disease. So just like the diagnosis of any psychiatric condition first requires us to rule out any general medical condition that could be the etiology underlying the presentation, we must hold the presenting complaint of fatigue to the same standards, however somatizing the presentation may appear.