Fatigue Evaluation and Management

Initial Assessment

The American College of Physicians recommends screening fatigue severity using a 0-10 numeric scale; if the score is ≥4, proceed with a focused evaluation targeting treatable conditions rather than extensive laboratory testing, prioritizing medication review, sleep assessment, and screening for depression 1, 2
Use a numeric rating scale (0-10) to quantify fatigue severity over the past 7 days, with scores of 0-3 (mild) requiring only routine rescreening at regular intervals with no further workup, and scores of 4-10 (moderate to severe) warranting immediate focused evaluation 1, 2, 3
Scores ≥7 typically indicate marked functional impairment and decreased physical functioning 1, 2

Document the onset, pattern, duration, and temporal changes in fatigue, as well as associated or alleviating factors, interference with normal functioning and daily activities, and changes in exercise or activity patterns since fatigue onset 1, 3, 4
Perform a thorough review of systems to identify affected organ systems, including lymph node assessment and evaluation for hepatosplenomegaly 1, 2

Review all current medications, including over-the-counter drugs, herbal supplements, and vitamins, and note any recent medication changes or potential interactions causing excessive drowsiness 3, 4
Assess sleep quality, quantity, and sleep hygiene practices, and screen for sleep disorders, including insomnia and sleep apnea 1, 3, 4
Screen for depression and anxiety, which frequently co-occur with fatigue, and note that fatigue and depression are independent conditions with different patterns 1, 3, 4

Keep initial laboratory testing limited and targeted, including complete blood count with differential, comprehensive metabolic panel, thyroid-stimulating hormone (TSH), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for inflammation 2, 3
Evaluate weight changes, caloric intake, and appetite, and assess for impediments to nutritional intake, fluid and electrolyte imbalances, and consider nutrition expert consultation if substantial abnormalities exist 3, 4

Implement a structured physical activity program with stretching and aerobic exercise 2-3 times weekly for 30-60 minutes, regardless of the underlying cause, to lower fatigue levels 2, 4
Treat any identified underlying causes, implement good sleep hygiene practices, address nutritional deficiencies with appropriate supplementation, and consider psychosocial interventions for emotional distress 2, 3, 4
Avoid psychostimulants and dietary supplements, as well as extensive imaging studies, unless red flags are present 2

Schedule regular follow-up visits and reassess fatigue severity at each visit, being aware that fatigue rarely occurs in isolation and often clusters with other symptoms 1, 3