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The main thing that I as a physician would want to know is whether you experience any other symptoms besides just feeling fatigued.In order to get a better idea about what is going on, physicians perform what is called “Review of Systems”. You have probably filled it out many times on your medical paperwork which is often used to speed up the process in the times when doctors can only spare fifteen minutes per patient. All of these questions may provide the necessary pieces of puzzle to uncover the cause of your fatigue.

Below are the questions that you will encounter in the common ROS. If you answer yes to any of the above, and you have not discussed it yet with your physician, then do not delay it any longer.

CONSTITUTIONAL:Do you have any fevers, weight loss, very poor appetite, night sweats or chills?
(If you answer YES to any of these, then you should see a doctor as soon as possible, you may be suffering from a serious medical problem)
EYES/EARS/MOUTH: Do you have any recent problems with your vision or hearing?
Do you have stuffy nose, difficulty breathing through the mouth, chronically mild sore throat, post nasal drip? Ear aches, ear ringing, or ear popping?
(Chronic allergies or sinusitis are a common cause of fatigue)
CARDIOVASCULAR:Chest pain, difficulty breathing, shortness of breath that appears with exertion much sooner than it used to, heart palpitations?
RESPIRATORY:Cough? Sputum? Wheezing? Frequent upper respiratory infections?
GASTROINTESTINAL:Do you have any stomach or intestinal problems, such as heartburn, indigestion, blood or mucous in your stool, diarrhea, constipation?
MUSCULOSKELETAL: Do you suffer from joint pain or stiffness? Aching muscles? Back pain?
GENITOURINARY:Do you have any urinary problems, such as bladder infections, increased frequency or volume of urination?
ENDOCRINE:Do you have hot flushes, temperature intolerance, hair loss, constant thirst?
HEMATOLOGIC:Do you have increased bleeding, easy bruising, any swollen or painful lymph nodes?
NEUROLOGIC:Have you experienced any numbness,tingling, headaches, muscle weakness. Any fainting spells? Memory loss?
PSYCHIATRIC:Have you been feeling depressed or overly anxious? Are you suffering from insomnia or nightmares?
SKIN: Any skin rashes, chronic itching, dermatitis or eczema? Skin color changes (such as looking too pale or areas of skin darkening).

These questions do not cover anything. I cannot stress enough that you must come to the doctor’s appointment prepared or you will forget to say something important. You must be your own patient advocate!

You doctor will not have time to think or ask you of everything possible, so think ahead of time of any changes or problems that you have noticed? Have these changes preceded the onset of fatigue or coincided with it?
OTHER IMPORTANT THINGS that need to be assessed
1) drug, alcohol and tobacco use
2) your risk for sexually transmitted diseases
3) your work environment, exposure to any chemicals
4) your daily stress level and sleep patterns
5) your diet
6) family history of any medical conditions
7) what medications and supplements you take

Your physician should perform a thorough physical exam. This means more than listening to your heart and lungs for about a minute!
Your tongue and nails can provide important clues to the etiology of your fatigue. Your eyes, nose and throat should be examined. Neck should be palpated for goiter. Lymph nodes should be palpated throughout the body. The doctor may also check the strength in your arms and legs, check your reflexes and depending on your symptoms do other parts of neurological exam.

The last part of the visit is ordering diagnostic imaging and labs. This will be tailored to each patient individually. For the initial workup, you should expect:
1) complete blood count
2) sedimentation rate
3) chemistry panel, including tests for liver and kidney function
4) urinalysis, including analysis for myoglobin
5) CPK (a byproduct of excessive muscle breakdown)
6) TSH (to check thyroid)
7) Vitamin B12 level

Your medical history and review of symptoms will dictate what other tests are indicated, and we will cover them in the upcoming blogs. It is not necessary to order all of these tests at once, as it will be costly and require too much blood. Therefore, your physician will order the first battery of tests based on his/her suspicion what is the most likely to be the cause in your case. However, if the first set of tests is unrevealing, and you are still suffering from fatigue despite having adequate sleep and normal stress and physical exertion levels, then it is important not to stop there and to keep searching.
The upcoming blogs will look into many of the common causes of fatigue and to help you make sure that you are not missing one of the possible explanations.

Image: Suat Eman /

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