“Doctor, I’m So Tired!” Refining Your Work-up for Chronic Fatigue

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Recent advances in our understanding of the pathophysiology of chronic fatigue and related disorders can help guide your response to this common complaint.



CASE › Lauren C, age 35, comes to the clinic because of fatigue, which she says started at least 8 months ago and has gotten progressively worse. The patient, a clerical worker, says she manages to do an adequate job but goes home feeling utterly exhausted each night.

Ms. C says she sleeps well, getting more than 8 hours of sleep per night on weekends but fewer than 7 hours per night during the week. But no matter how long she sleeps, she never awakens feeling refreshed. Ms. C reports that she doesn’t smoke, has no more than 4 alcoholic drinks per month, and adheres to an “average” diet. She is too tired to exercise.

Ms. C is single, with no children. Although she says she has a strong network of family and friends, she increasingly finds she has no energy for socializing. If Ms. C were your patient, what would you do?

Patients with an organ-based medical illness tend to associate their fatigue with activities that they are unable to complete, while those with fatigue that is not organ-based typically say that they're tired all the time.Fatigue is a common presenting symptom in primary care, accounting for about 5% of adult visits.1 Defined as a generalized lack of energy, fatigue that persists despite adequate rest or is severe enough to disrupt an individual’s ability to participate in key social and/or occupational activities warrants a thorough investigation.

Because fatigue is a nonspecific symptom that may be linked to a number of medical and psychiatric illnesses or medications used to treat them, determining the cause can be difficult. In about half of all cases, no specific etiology is found.2 This review, which includes the elements of a work-up and management strategies for patients presenting with ongoing fatigue, will help you arrive at the appropriate diagnosis and provide optimal treatment.

Next page: Defining the terms of chronic fatigue >>


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