FIRST THINGS FIRST: RULE OUT RED FLAGS
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? Start with an ophthalmologist or ENT, they may may be able to find a link between these symptoms and your fatigue.
Do you have stuffy nose, difficulty breathing through the mouth, chronically mild sore throat, post nasal drip? Ear aches, ear ringing, or ear popping?
Your fatigue may be due to sinusitis or allergies. Read the blog about nasal allergies.
CARDIOVASCULAR:Chest pain, difficulty breathing, shortness of breath that appears with exertion much sooner than it used to, heart palpitations? – Definitely see a cardiologist and have your heart checked out.
RESPIRATORY:Cough? Sputum? Wheezing? Frequent upper respiratory infections? You may have chronic bronchitis, an undiagnosed asthma or a chronic lung infection.
GASTROINTESTINAL:Do you have any stomach or intestinal problems, such as heartburn, indigestion, blood or mucous in your stool, diarrhea, constipation? In that case you need to see Gastroenterologist. Also see an article on Celiac Disease, which is just one of the many possible explanations to your symptoms.
MUSCULOSKELETAL: Do you suffer from joint pain or stiffness? Aching muscles? Back pain? You may have a muscular fatigue disorder or a connective tissue disease such as lupus or rheumatoid arthritis. You may also have fibromyalgia, which is a very common cause of fatigue in women. Leg muscle cramps may be a sign of magnesium deficiency.
GENITOURINARY:Do you have any urinary problems, such as bladder infections, increased frequency or volume of urination? As your doctor for a urine sample and a glucose check. The increased urine volume may be due to diabetes or kidney dysfunction and lead to dehydration that makes you tired.
ENDOCRINE:Do you have hot flushes, temperature intolerance, hair loss, constant thirst? Your fatigue may be due to menopause or thyroid issues.
HEMATOLOGIC:Do you have increased bleeding, easy bruising, any swollen lymph nodes? See either your PCP or a hematologist (blood specialist) to make sure you don’t a serious blood disorder.
NEUROLOGIC:Have you experienced any numbness,tingling, headaches, muscle weakness. See a neurologist to rule out a neurologic disorder. You may also have Vitamin B12 deficiency.
PSYCHIATRIC:Have you been feeling depressed or overly anxious? Are you suffering from insomnia or nightmares? Your fatigue may be due to depression or poor sleep (see Posts about Sleep and Depression.) If you take care of other people, you may want to read my post about Compassion Fatigue.
If you always seem to doze off during the day, read my post about Narcolepsy.
SKIN: Any skin rashes, chronic itching, dermatitis or eczema? Skin color changes (such as looking too pale or areas of skin darkening). A rash or change in skin pigmentation can provide a clue to a systemic illness.
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.