Content Objective: Fatigue
By the end of the Family Medicine Clerkship, the medical student will be able to:
- Conduct a patient interview so as to:
- Define what the patient means by “fatigue” and distinguish from other concerns e.g. depression (or other mood disorders), muscle weakness, decreased exercise tolerance ± shortness of breath
- Identify clinical symptoms/red flags that suggest a secondary etiology:
- Anemia (e.g. exertional dyspnea, dyspnea at rest, bounding pulses, palpitations, “roaring in the ears”, lethargy, confusion)
- Hypothyroidism (e.g. weight gain, impaired memory, constipation, cold intolerance)
- Sleep Apnea
- Cardiac disease
- Identify red flags that may suggest psychosocial concerns/stressors and how these may impact the differential diagnosis and/or management, e.g. shift work, homelessness, social isolation, single parent, addiction, recent losses/bereavement.
- Elicit a history of sleep habits
- Conduct a relevant physical exam to refine the differential diagnosis of fatigue, including:
- General appearance (level of alertness, psychomotor agitation, grooming.)
- Presence of lymphadenopathy.
- Evidence of thyroid disease (goiter, nodule, ophthalmologic changes.)
- Cardiopulmonary exam (signs of CHF, chronic respiratory disease.)
- Neurological exam (muscle bulk, tone, strength, deep tendon reflexes.)
- Include “watchful waiting” when appropriate as a diagnostic and/or management tool for fatigue to avoid over-investigation/“shotgun” approach.
- Propose and act on initial investigations based upon differential diagnosis including:
- Normocytic anemia
- Microcytic anemia (iron deficiency anemia, thalassemia, chronic disease)
- Macrocytic anemia (alcoholism, liver disease, hypothyroidism, megaloblastic anemia)
- For patients with insomnia identify when sleep studies are appropriate and counsel patients on behavioral and pharmacological management options.
Mandatory Clinical Encounter
- Rosenthal, et al. Fatigue: An Overview. Am Fam Physician 2008 Nov 15;78(10):1173-1179
- Fatigue clinical card, SHARC-FM
- Iron Deficiency, BCGuidelines.ca 2010
- Thyroid Function Tests, BCGuidelines.ca 2010
- Thyroid Dysfunction, TOP 2014
- Adult Insomnia, TOP 2015
- Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, TOP 2016
* Where a specific resource is not listed for a particular objective, please refer to recommended general texts/websites. Resources have often been selected from the Clinical Practice Guidelines and Protocols in British Columbia and Alberta’s Towards Optimized Practice Clinical Practice Guidelines. These are often concise summaries of national guidelines.