Transcript: Diagnostic Approach to Fatigue in Primary Care

Diagnostic Approach to Fatigue in Primary Care Transcript

Liz Rohr (00:00):

Well, Hey, there, it's Liz roar from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Liz Rohr (00:15):

So in this week's episode, I'm gonna be talking about the diagnostic approach to fatigue in primary care. So I just wanna normalize that this is a really tricky differential diagnosis because it's super broad and it's another one of those chief complaints where it could be something that's non-acute and not life threatening, or it could be a little bit more on the acute life threatening side. So it's a, this adds a little bit of stress to that hugely broad differential diagnosis. So the way I'm gonna, you know, have this episode is that I'm gonna focus on the initial approach, the history questions, the general categories of differential diagnosis, and then the approach to the physical exam and the testing. Okay. So as part of this episode, I made a cheat sheet and that is actually inside the digital NP binder. So if you would like to purchase a copy, the link is down below this video.

Liz Rohr (01:11):

However, feel free to take some notes as we go in the cheat sheet, we talk a little bit more about the differential diagnoses to, to watch out for as like a quick reference at your desk. So that's an option if you'd like it. So the first branching point that you wanna assess for is, is this an acute fatigue, meaning is it in the last, you know, couple days, weeks to a month, or is it more in that subacute to chronic stage? Is it a month or longer for acute fatigue? It is more likely associated with things like, or an acute illness, respiratory or otherwise. So that's more of the focus of where you wanna look, although could still be the same thing as chronic, right? We'll talk, we'll, we'll get into it. We'll talk about it, but that's like your initial branching point. The other place to start in your history is with old cart.

Liz Rohr (02:01):

I talk about this all the time is my specific approach to obtaining a history in in my, any visit that is a symptom based visit. So this is again, onset location, duration, characteristics, associated factors, relieving factors, and either time or treatment or both, I usually ask both. But when you can always use that as your framework for any chief complaint specific to fatigue, though, you wanna ask about, is this like a gradual onset? Was it a sudden onset? Like, what are the other associated symptoms that you have? Is it just fatigue by itself? Or do you have other physical issues, which I'll talk about in a second, but those are kind of like the main places that I'm starting with fatigue in addition to all of those questions. And then the next place on that I go to is what medications are they taking prescribed over the counter supplements or substances that they're using marijuana, heroin, cocaine, etc.

Liz Rohr (02:58):

Those are really crucial to ask about when it comes to fatigue, because those contribute so often to their symptoms. And whenever we ask about those things, we also wanna clarify, how much are they using? What quantity, right. Can we get really specific about that? How often, and whether it's every day or an approximation, right? How much alcohol are they using? How often are they using this herbal supplement since when? Right. And then another thing again, I always ask it's I kind of tie it in with old cart, but it's like a status report. Is this getting worse? Is it getting better? Is it getting, is it staying the same? Has it not changed at all throughout the whole time? And that is a really helpful snapshot for the trajectory of where we're going. Like this just started and it's getting really bad and I'm short of breath.

Liz Rohr (03:44):

Right. That's very different than like, oh, I've had this fatigue for like a year. So basically I've had this fatigue since COVID started. Right? So that's like, those are very different contexts. The next thing you wanna ask about that's so important for fatigue is asking about their sleep hygiene. And I just feel like this cringe at the phrasing of sleep hygiene, cause it just, I don't know. It just feels like it's like, oh really? But like, no, it's, it's like actually really important and it's not that hard to ask about. Right. And it is actually like median important. Right. So what time do they go to sleep at night? Do they wake up at the same time? Do they go to bed at the same time every night? Or is it different every night? When do they wake up? How many hours of sleep are they getting?

Liz Rohr (04:20):

Is it the same all the time or does it vary? Why is it varying? Is it because they work night shift? Is it because they have a newborn at home? Is it because they're waking up in the middle of the night to go to the bathroom? Right. Like getting into that will give you a lot of information about where you go next with your questioning. Another thing I ask patients, do they feel rested in the morning? Or do they feel like more fatigue during the day? Is it there all the time? Do they snore at night? Is there anybody at home that could tell them if they snore more context around their bedtime routine? Do they take anything to go to sleep at night? Do they have a dark cool place to sleep, which is kind of like best practice for sleep hygiene?

Liz Rohr (05:00):

Do they use any caffeine and that's kind of the next part of sleep hygiene? What are they using? How much, how often? Right. So coffee, tea, soda. Is it in the morning? Is it at night? Is it every day? Right? These are the, I don't ask it this fast, but I tend to give patients these kinds of options when I'm doing my history. Because again, there's a lot of questions to ask and it's a lot of information to get to. So it gives, them an example of like what I'm looking for, the general gist of it. Right. So they're not just like I don't know. Yes. So depression screening, that is the next kind of like most important thing with, fatigue. So often, anecdotally speaking of course, most of the time it's either related to depression or anxiety, related to sleep and sleep habits,

Liz Rohr (05:44):

And then anemia is another one too, but it's really important to assess for depression. I'll talk about anemia in a second, but you have to ask, I mean, one of the ways that to make this easier, and again, this is a longer visit sometimes because there's so many history questions they may or may not volunteer all of the answers so you have to ask a lot of things. Sometimes it's apparent sometimes it's not right. And so you wanna ask about depression and anxiety symptoms, but I also do a screener for my literate patients or I get assistance from my medical assistant to help a patient fill it out if they are not literate. And it's also in multiple languages, it's called the PHQ nine. If you haven't used that already. That's the depression screener that I use. There's also the GAD seven, which is generalized anxiety disorder, seven questions...

Liz Rohr (06:28):

They're both available in multiple languages, which is helpful. It's a, it's a screening tool, right? It's not necessarily a diagnostic tool, but it's nice to kind of start that conversation of like, is this contributing potentially to your fatigue, the other kind of like main, most common causes of fatigue that you wanna think about are, again, anemia comes up so often. So we wanna ask like some history questions around that. Do they have any, have they had anemia in the past um, do they have any risk factors for anemia? Like menorrhagia things like that, depending on the patient in front of you. And I'm looking at my notes, that's why I'm looking over here. You wanna ask about, well, let, let's get into the body systems, right? So at this point, hopefully in your questioning, your line of questioning, you have some sort of inkling of like what body system we're talking about.

Liz Rohr (07:18):

Maybe you don't, maybe you do, hopefully you do, because then you can kind of steer your questioning in that direction. However, if you don't have a clear picture, then you kind of just have to go back to square one of like, what are the, what are the, what are the general body categories that we're thinking of that could contribute to fatigue? So honestly you can just do a full ROS and you could even do like a full head to toe assessment if you wanted to, just to like cover your bases. But there's, there's a, because the reason I'm saying that is cuz I'm gonna go through the body systems, but there's a lot of them. So anyway, the hack is that you do all of them. Right. But it lets, if we narrow in a little bit more, we're talking about red flags here, right? So we're thinking about cardiac.

Liz Rohr (08:00):

Are there any, again, differentials aside, it's more specific in the cheat sheet in the binder, but differentials aside, anything cardiovascular-wise, what are the symp-what the questions you would ask shortness of breath, chest pain edema, etc. Pulmonary, helpful to know. Right? Hopefully they volunteered some symptoms infectious, which is like any body's system, right? Fever, chills, night sweats, lymphadenopathy. What are the risk factors there? We wanna think about neurologic, neurologic and musculoskeletal. Again, even if you don't know the differentials of the neurologic diagnoses, can we do a neurologic exam, neurologic review of systems, and can we, if they have any muscle symptoms, can you like a muscular exam for their strength or weakness? Things like that. I've already mentioned psychological asking about depression, anxiety, other mental illnesses or symptoms of, of other mental illnesses. The, the two other big two to three. Mm it's.

Liz Rohr (08:54):

Like it could be anything. Right. But you wanna think about endocrine again, even if you don't know the differentials hypothyroidism, do they have any heat, cold intolerance? Any sort of like weight gain, things like that. Rheumatologic again, fancy diagnoses aside. Do they have any joint pains, rashes other potential signs and symptoms. And then I have to throw in renal, I'm obsessed with nephrology. It's not necessarily like your first symptom of renal impairment, but it could be. So yeah. So those are the body systems we like red flag wanna think about, especially cardiac and pulmonary, right. And infectious. Right? What are the things that could get worse the fastest? So when you get to your physical exam, you wanna focus in again on those body systems, cardiac pulmonary, you wanna do a thyroid exam, You wanna check for a lymphadenopathy again, but depending on your ROS and your history, you wanna do a neurologic exam...

Liz Rohr (09:50):

You wanna do a strength assessment of their extremities if they're reporting any muscle pain or weakness. And obviously you wanna look at their skin too. Right? So there's a little bit of like a joke in like the real world community. Not, not like this community, but like the real world of healthcare that a lot of patients come in with fatigue providers of any type, right? Not just nurse practitioners, physicians, PAs DOs, etc. Providers will do labs to like buy some time because it's like not very clear what they're coming in for. So like just to normalize, like there, sometimes you'll go through all of these questions and it's like, not that apparent what it could be going on. We do wanna do a lab assessment regardless. We want it to be a targeted lab assessment based on our history and our physical exam findings.

Liz Rohr (10:34):

But just know that that's like, that's like a, a very common thing. Unfortunately, there aren't like guidelines that are guiding specific like, oh, for fatigue, you wanna do these labs. It's really dependent on the differentials in your history taking. Right. But for the most part, patients who have fatigue, you're gonna focus on things like a CBC with differential, right? Cuz we're looking for some sort of anemia or heme malignancy or potential issue there. We wanna do a complete metabolic panel because we wanna look at again liver kidneys, electrolyte abnormalities, which might point to some endocrine abnormalities, TSH free T4, perhaps total T3. And then the rest of them are really dependent on the patient in front of you. Right. So have they had screening for HIV or are they at risk for HIV? Again, infectious is a potential option. Hepatitis C have they been screened for hepatitis C or do they have risk factors for that?

Liz Rohr (11:26):

Everybody should have HIV and Hep C at some point baseline. Right? Do they need a urinalysis? Be, are they at risk for a UTI? Are they an older patient who might just have fatigue? That is that's their presentation of their infection and this is all up to your clinical judgment. Right. But yeah, it, it real, like that's like the initial kind of like general approach, like first pass and then again, other labs might be appropriate or other testing might be appropriate depending on the patient in front of you, their constellation of symptoms, what they've told you, things like that. So hopefully this is a helpful first approach to fatigue. Again, if you wanna grab that cheat sheet inside the Digital NP binder the link is down below. Thank you so very much for watching, hang in there and I'll see you soon.