Basics
Description
- A subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest
- Fatigue occurs with or without objective findings on physical exam.
- Fatigue is a common complaint in people with and without systemic disease, which makes this complaint a challenge to practicing physicians.
Etiology
- The specific mechanisms of fatigue are unknown.
- Hematologic:
- Endocrine:
- Thyroid disorders
- Adrenal insufficiency
- Diabetes
- Pregnancy
- Malignancy:
- Psychiatric:
- Chronic pain
- Emotional distress
- Depression
- Eating disorders
- Chemical dependency
- Withdrawal syndromes
- Sleep disorders:
- Cardiac and pulmonary disorders
- Infections acute and chronic
- Rheumatic and autoimmune disorders
- Nutritional deficiencies including electrolyte abnormalities
- Physical inactivity and deconditioning
- Medications
- Chronic fatigue syndrome:
- Symptom complex defined by the CDC
- Severe chronic fatigue lasting >6 mo
- Not explained by any medical or psychiatric diagnosis
- Presence of 4 or more of the following 8 symptoms:
- Headache
- Arthralgias
- Sleep disturbances
- Lymphadenopathy
- Exercise intolerance
- Myalgias
- Impaired memory/concentration
- Sore throat
Diagnosis
Signs and Symptoms
- Fatigue is a subjective complaint of exhaustion or tired sensation that interferes with normal activities of life, and symptoms do not resolve with sleep.
- There are no specific signs of fatigue, but frequently physical signs may hint at the underlying cause of complaint.
History
- Onset, pattern, duration of fatigue
- Associated symptoms: Fever, night sweats, weakness, dyspnea, weight loss/gain, sleep patterns
- Past medical and surgical history
- Psychiatric history: Emotional and mental stressors, depression
- Social history: Alcohol, drug use, major life events
- Medications
- Full review of systems
Physical Exam
- A complete physical exam should be focused on trying to identify an underlying cause for patients symptoms. No physical findings are specific to fatigue.
- A partial list of physical exam findings which may suggest an underlying cause include:
- Vital signs
- HEENT
- Pupils for evidence of toxidrome
- Sclera for icterus in liver disease
- Conjunctiva pale in anemia
- Thyroid for enlargement, pain, or nodule that would suggest dysfunction
- Heart: Murmurs or S3 may suggest LV dysfunction.
- Lung: Abnormal AP diameter or breath sounds may suggest chronic or acute lung disease.
- Abdomen: Tenderness or masses should be investigated.
- Skin: Rash may suggest infectious or autoimmune disease, lack of turgor may suggest dehydration, hyperpigmentation in Addison disease.
- Neurologic: True weakness or areflexia may suggest neuromuscular disorder, all new focal weakness should be investigated.
- Musculoskeletal: Indwelling IV lines or dialysis catheters should prompt investigation of electrolyte abnormality or occult bacteremia.
Essential Workup
- Because fatigue is a subjective complaint, the essential workup is directed at identification of an underlying cause.
Diagnosis Tests & Interpretation
Lab
- Lab evaluation should be directed by findings of history and physical exam.
- CBC:
- Screen for anemia or leukemia.
- Serum glucose:
- Both hyperglycemia and hypoglycemia can present with fatigue.
- Pregnancy test
- Electrolytes with BUN/creatinine
- Thyroid-stimulating hormone:
- Screen for hypothyroidism.
- Urine drug screen
Imaging
Imaging/special test: Special tests are reserved for evaluation of abnormal physical exam findings or history suggesting further evaluation.
Diagnostic Procedures/Surgery
Any diagnostic procedures considered should be reserved for evaluation of abnormal physical exam findings or history suggesting further evaluation.
Differential Diagnosis
- Infection:
- Bacteremia
- Urosepsis
- Pneumonia
- Viral syndromes
- Abscess
- Epstein-Barr virus, monospot
- Cytomegalovirus
- HIV
- Human herpesvirus 6
- Immunologic/connective tissue:
- Rheumatologic (rheumatoid arthritis, systemic lupus erythematosus, juvenile rheumatoid arthritis)
- Osteoarthritis
- Fibromyalgia
- Myasthenia gravis
- Lambert-Eaton syndrome
- Neoplastic:
- Solid or hematologic cancers
- Metabolic:
- Electrolyte abnormalities
- Mitochondrial diseases
- Bromism
- Hematologic:
- Anemia
- Hypovolemia
- Hemoglobinopathy
- Endocrine:
- Hyperthyroid or hypothyroid
- Adrenal insufficiency
- Diabetes
- Hypoglycemia
- Neurologic:
- Multiple sclerosis
- Cerebrovascular accident
- Amyotrophic lateral sclerosis
- Cardiovascular:
- Pulmonary:
- Pneumonia
- Chronic obstructive pulmonary disease
- Asthma
- Sleep apnea
- GI:
- Reflux
- Peptic ulcer disease
- Liver disease
- Autonomic dysfunction
- Lifestyle:
- Excessive or insufficient exercise
- Obesity
- Psychiatric:
- Major depression
- Anxiety
- Grief
- Stress
- Medication related:
- Drug interactions
- Commonly caused by BP, cardiovascular, psychiatric, and narcotic medications
- Dehydration
Treatment
Pre-Hospital
Evaluate vital signs:
- Collect relevant information that could help psychosocial evaluation.
Initial Stabilization/Therapy
- ABCs
- Administer supplemental oxygen for hypoxia.
- IV fluid bolus for signs of dehydration
Ed Treatment/Procedures
- Treatment should be directed to correction of the underlying cause of fatigue:
- Identify and treat any infectious process.
- Correct metabolic and hematologic disturbances.
- Diagnose progressive neurologic disease and acute psychiatric crisis.
- Initiate workup for endocrine and neoplastic disease.
- Stop any offending medications or toxins.
- Most cases will not have identifiable cause, so reassurance and close follow-up is required.
- Recommend appropriate diet, exercise regimen, and consistent sleep cycles.
Medication
First Line
Medication should be reserved for treatment of the underlying cause of symptoms.
Follow-Up
Disposition
Admission Criteria
- Underlying disease requiring IV medication or monitoring
- Failure to thrive as outpatient
- Unable to provide for self
Discharge Criteria
- Able to care for self
- Serious disturbances have been excluded.
- Adequate follow-up is arranged.
Issues for Referral
Most patients who are evaluated for fatigue in the ED should be referred:
- When the cause of a patients fatigue symptoms have been clearly identified, referral should be directed to the appropriate specialist.
- When the cause of a patient's fatigue symptoms are not clearly identified, a primary care referral is indicated.
Pearls and Pitfalls
- Fatigue is a subjective symptom complex, and a complete history and physical exam are needed.
- Beware of patients with unreliable history and physical exam. The elderly, children, intoxicated, and those with decreased mental ability may all have life-threatening disease and present with a complaint of fatigue.
Additional Reading
- Kitai E, Blumberg G, Levy D, et al. Fatigue as a first-time presenting symptom: Management by family doctors and one year follow-up. Isr Med Assoc J. 2012;14(9):555-559.
- Manzullo EF, Escalante CP. Research into fatigue. Hematol Oncol Clin North Am. 2002;16(3):619-628.
- Mawle AC. Chronic fatigue syndrome. Immunol Invest. 1997;26(1-2):269-273.
- Morrison RE, Keating HJ 3rd. Fatigue in primary care. Obstet Gynecol Clin North Am. 2001;28(2):225-240, v-vi.
- Nemec M, Koller MT, Nickel CH, et al. Patients presenting to the emergency department with non-specific complaints: The Basel Non-specific Complaints (BANC) study. Acad Emerg Med. 2010;17(3):284-292.
Codes
ICD9
- 729.1 Myalgia and myositis, unspecified
- 780.71 Chronic fatigue syndrome
- 780.79 Other malaise and fatigue
- 300.5 Neurasthenia
- 719.49 Pain in joint, multiple sites
ICD10
- M79.1 Myalgia
- R53.82 Chronic fatigue, unspecified
- R53.83 Other fatigue
- F48.8 Other specified nonpsychotic mental disorders
- M25.50 Pain in unspecified joint
SNOMED
- 84229001 Fatigue (finding)
- 52702003 Chronic fatigue syndrome (disorder)
- 68962001 Muscle pain (finding)
- 442099003 Psychogenic fatigue (finding)
- 57676002 Joint pain (finding)