Diagnostic Approach to Fatigue in Primary Care
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Show notes:
Fatigue is a tricky clinical topic that can seem overwhelming in a primary care visit – even for seasoned NPs. Is it acute or chronic? Is it a standalone symptom, or are there chronic conditions that make the picture unclear? What impact does the patient’s age have on this?
Where do you even start?
Diagnostic Approach to Fatigue in Primary Care
This week, let’s talk about what you need to know to be prepared for the patient with fatigue. We’ll strategize how to get the history you need, develop an approach to diagnosis, and cover the top questions to ask to be both comprehensive and efficient in your visit.
We’ll go over the body systems you MUST assess and chronic causes to rule in and out in your fatigue assessment. You’ll also learn the labs that you want to be sure to order to have the complete clinical picture and what to do when the assessment is inconclusive.
You will come away with the things that you need to develop a game plan to dig down into causes of your patient’s fatigue without overwhelming yourself – or missing any red flags.
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WEBVTT
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus you'll find links to all the episodes with
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extra goodies over at realworldnp.com slash podcast. So in this week's episode, I'm going
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be talking about the diagnostic approach to fatigue in primary care. So I just want to
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normalize it. This is a really tricky differential diagnosis because it's super broad and it's
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another one of those chief complaints where it could be something that's non-acute and
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not life-threatening or it could be a little bit more on the acute life-threatening side.
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So it just adds a little bit of stress to that hugely broad differential diagnosis. So
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the way I'm going to have this episode is that I'm going to focus on the initial approach,
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the history questions, the general categories of differential diagnosis, and then the approach
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to the physical exam and the testing. So as part of this episode, I made a cheat sheet and
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that is actually inside the digital NP binder. So if you would like to purchase a copy,
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the link is down below this video. However, feel free to take some notes as we go. In the
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cheat sheet, we talk a little bit more about the differential diagnoses to watch out for
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as a quick reference at your desk. So that's an option if you'd like it. So the first
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branching point that you want to assess for is, is this an acute fatigue, meaning
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is it in the last couple of days, weeks to a month, or is it more in that subacute
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to chronic stage? Is it a month or longer? For acute fatigue, it is more likely associated
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with things like stress or an acute illness, respiratory or otherwise. So that's more of the
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focus of where you want to look, although could still be the same thing as chronic,
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right? We'll talk, we'll, we'll get into it. We'll talk about it, but that's like your
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initial branching point. The other place to start in your history is with old cart. I
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talk about this all the time. That is my specific approach to obtaining a history in, in
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any visit that is a symptom based visit. So this is again, onset, location, duration,
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characteristics, associated factors, relieving factors, and either time or treatment or both.
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I usually ask both. But when you can always use that as your framework for any chief
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complaint specific to fatigue, though, you want to ask about, is this like a gradual
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onset? Was it a sudden onset? Like what are the other associated symptoms that you
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is it just fatigue by itself or do you have other physical issues, which we'll talk about
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in a second. But those are kind of like the main places that I'm starting with fatigue,
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in addition to all of those questions. And then the next place that I go to is what
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medications are they taking? Prescribed, over the counter, supplements or substances that
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they're using, marijuana, heroin, cocaine, et cetera. Those are really crucial to ask about
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when it comes to fatigue, because those contribute so often to their symptoms.
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And whenever we ask about those things, we also want to clarify how much are they using,
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what quantity, right? Can we get really specific about that? How often and whether it's
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every day or an approximation, right? How much alcohol are they using? How often are they using
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this herbal supplement since when, right? And then another thing, again, I always ask,
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I kind of tie it in with old cart, but it's like a status report. Is this getting worse?
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Is it getting better? Is it staying the same? Has it not changed at all throughout the whole
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time? And that is a really helpful snapshot for the trajectory of where we're going.
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This just started and it's getting really bad and I'm short of breath, right? That's
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very different than like, oh, I've had this fatigue for like a year. Basically, I've had
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this fatigue since COVID started, right? So those are very different contexts.
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The next thing you want to ask about that's so important for fatigue is asking about their
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hygiene. And I just feel like this cringe at the phrasing of sleep hygiene because it just,
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I don't know, it just feels like it's like, oh, really? But like, no, it's actually really
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important and it's not that hard to ask about, right? And it is actually like meaty and
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important, right? So what time do they go to sleep at night? Do they go to bed at the same
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time every night or is it different every night? When do they wake up? How many hours
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of sleep are they getting? Is it the same all the time or does it vary? Why is it varying?
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Is it because they work night shift? Is it because they have a newborn at home? Is it
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because they're waking up in the middle of the night to go to the bathroom, right? Like,
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getting into that will give you a lot of information about where you go next with
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your questioning. Another thing I ask patients, do they feel rested in the morning or do they
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feel like more fatigue during the day? Is it there all the time? Do they snore at night? Is
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there anybody at home that could tell them if they snore? More context around their bedtime
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Do they take anything to go to sleep at night? Do they have a dark, cool place to sleep, which
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is kind of like best practice for sleep hygiene? Do they use any caffeine? That's kind of the
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next part of sleep hygiene. What are they using? How much? How often, right? So coffee, tea,
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soda. Is it in the morning? Is it at night? Is it every day, right? I don't ask it this
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fast, but I tend to give patients these kinds of options when I'm doing my history, because
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again, it's a lot of questions to ask and it's a lot of information to get to. So it gives
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them an example of what I'm looking for, the general gist of it, right? So they're not just
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like, uh, I don't know, yes. So depression screening, that is the next kind of most
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important thing with fatigue. So often, anecdotally speaking, of course, most of the time
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it's either related to depression or anxiety, related to their sleep and sleep habits,
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and then anemia is another one too. But it's really important to assess for depression.
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I'll talk about anemia in a second, but you have to ask. I mean, one of the ways that
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to make this easier, and again, this is a longer visit sometimes because there's so many
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history questions, they may or may not volunteer all of the answers. So you have to ask a lot
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of things. Sometimes it's apparent, sometimes it's not, right? And so you want to ask about
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depression and anxiety symptoms. But I also do a screener for my literate patients,
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or I get assistance from my medical assistant to help a patient fill it out if they are not
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literate. Um, and it's also in multiple languages is called the PHQ-9. If you haven't used that
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already, that's the depression screener that I use. There's also the GAD-7, which is
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generalized anxiety disorder, seven questions. They're both available in multiple languages,
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which is helpful. It's a, it's a screening tool, right? It's not necessarily a diagnostic
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tool, but it's nice to kind of start that conversation of like, is this contributing
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potentially to your fatigue? The other kind of like main, most common causes of fatigue that
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you want to think about are, again, anemia comes up so often. So we want to ask like some
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history questions around that. Do they have any, have they had anemia in the past? Um,
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do they have any risk factors for anemia like menorrhagia, things like that, depending
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on the patient in front of you. And I'm looking at my notes. That's why I'm looking
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here. Um, you want to ask about, well, let's get into the body systems, right? So at this point,
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hopefully in your questioning, your line of questioning, you have some sort of inkling
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of like what body system we're talking about. Maybe you don't, maybe you do. Hopefully you do
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because then you can kind of steer your questioning in that direction. However,
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if you don't have a clear picture, then you kind of just have to go back to square one
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of like, what are the, what are the, what are the general body categories that we're thinking
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of that could contribute to fatigue? So honestly, you can just do a full ROS and you
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could even do like a full head to toe assessment if you wanted to just to like cover your bases.
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But there's, there's a, because the reason I'm saying that is because I'm going to go
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through the body systems, but there's a lot of them. So anyway, the hack is that you do
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all of them, right? But it lets, if we narrow in a little bit more, we're talking
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about red flags here, right? So we're thinking about cardiac. There are any, again,
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differentials aside, it's more specific in the cheat sheet and the binder,
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but differentials aside, anything cardiovascular wise, what are the simple, the questions you
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would ask? Shortness of breath, chest pain, edema, et cetera. Pulmonary, helpful to know,
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right? Hopefully they've volunteered some symptoms. Infectious, which is like any
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body system, right? Fever, chills, night sweats, lymphadenopathy. What are the risk
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factors there? We want to think about neurologic, neurologic and musculoskeletal. Again,
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even if you don't know the differentials of the neurologic diagnoses, can we do a neurologic
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exam, neurologic review of systems? And can we, if they have any muscle symptoms,
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can we do like a muscular exam for their strength or weakness, things like that?
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I've already mentioned psychological asking about depression, anxiety, other mental
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illnesses or symptoms of other mental illnesses. The two other big, two to three, it's like it
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could be anything, right? But you want to think about endocrine. Again, even if you don't know
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the differentials, hypothyroidism, do they have any heat, cold intolerance, any sort of like
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weight gain, things like that. Rheumatologic, again, fancy diagnoses aside, do they have any
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rashes, other potential signs and symptoms. And then I have to throw in renal. I'm obsessed with
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nephrology. It's not necessarily like your first symptom of renal impairment, but it could be.
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So yeah, so those are the body systems that we like red flag want to think about,
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especially cardiac and pulmonary, right? And infectious, right? What are the things that
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could get worst, the fastest? So when you get to your physical exam, you want to focus
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again on those body systems. Cardiac, pulmonary, you want to do a thyroid exam. You want to check
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for a lymphadenopathy. Again, depending on your ROS and your history, you want to do a neurologic
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exam. You want to do a strength assessment of their extremities if they're reporting any
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muscle pain or weakness. And obviously you want to look at their skin too, right?
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So there's a little bit of like a joke in like the real world community, not like this
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community, but like the real world of healthcare that a lot of patients come in with fatigue
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providers of any type, right? Not just nurse practitioners, physicians, PAs, DOs, et cetera.
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Providers will do labs to like buy some time because it's like not very clear what they're
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coming in for. So like just to normalize, like sometimes you'll go through all of these
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questions and it's like not that apparent what it could be going on. We do want to do a
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lab assessment regardless. We want it to be a targeted lab assessment based on our history
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and our physical exam findings, but just know that that's like a very common thing.
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Unfortunately, there aren't like guidelines that are guiding specific like, oh, for fatigue,
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you want to do these labs. It's really dependent on the differentials and your history taking,
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right? But for the most part, patients who have fatigue, you're going to focus on things like
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a CBC with differential, right? Because we're looking for some sort of anemia or heme
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malignancy or potential issue there. We want to do a complete metabolic panel because we
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look at again, liver, kidneys, electrolyte abnormalities, which might point to some
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endocrine abnormalities, TSH, free T4, perhaps total T3. And then the rest of them are really
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dependent on the patient in front of you, right? So have they had have screening for HIV
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or are they at risk for HIV? Again, infectious is a potential option. Hepatitis C,
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have they been screened for hepatitis C or do they have risk factors for that? Everybody
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should have HIV and Hep C at some point baseline, right? Do they need a urinalysis? Are they at
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risk for a UTI? Are they an older patient who might just have fatigue that is presenting,
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that's their presentation of their infection. And this is all up to your clinical judgment,
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right? But yeah, it's like, that's like the initial kind of like general approach,
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like first pass. And then again, other labs might be appropriate or other testing might be
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depending on the patient in front of you, their constellation of symptoms, what they've told you,
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things like that. So hopefully this is a helpful first approach to fatigue. Again,
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if you want to grab that cheat sheet inside the digital NP binder, the link is down below.
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Thank you so very much for watching. Hang in there and I'll see you soon.
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care to their patients. If you haven't gotten your copy of the ultimate resource guide for the
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new NP, head over to realworldnp.com slash guide. You'll get these episodes sent straight
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to your inbox every week with notes from me, patient stories and extra bonuses I really just
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don't share anywhere else. Thank you so much again for listening. Take care and talk soon.
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