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I’m Deathly Tired….The Fatigue Work Up

Neda Frayha, MD and Heidi James, MD
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No me gusta!

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Fatigue is a very common symptom in primary care.  Unfortunately, the cause is rarely found. Taking a thorough history and doing a physical exam may identity the cause of the fatigue or help direct further investigations.  The differential is wide and encompasses many cardiovascular, respiratory, endocrinologic, and psychiatric conditions. Even with such a broad differential, many causes remain categorized as “NYD”.  Neda and Heidi describe a tier-like approach to ordering investigations and discuss how to help you patient manage this debilitating symptom.

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Sarah H., ARNP -

Thanks for the great overview. Do you include EKG in your "first pass" work up?

Heidi J., MD -

Hi Sarah - We'll include an EKG if our history and physical leads us down the CV disease as a potential cause (i.e. bradycardia on exam, syncope on hx) , but it is not part of our usual first pass.

Ian L., Dr -

There is recognition of Primary Hyperparathyroidism as common endocrine disorder in persons over 65 -1.5% particularly Post Menopausal Women -2.5 to 3%
Therefore a Serum Calcium ionised and ionised and albumin are definetly on the list for fatigue in over 65 and Post Menopausal Women.
There is debate about treatment but the consensus is at this time in mild asymptomatic cases watchful waiting and yearly tests of Calcium Parathroid Hormone Bone Mineral Density and good fluid intake is satisfactory .
Parathroidectomy on 2% of those over 65 seems radical !

John K., MD -

Great overview. It's reassuring to know that this is just hard to figure out, it's not just me. The stats will be helpful in my initial discussion with folks to sort of gauge expectations.

Heidi J., MD -

Thanks, John! Managing expectations is key to so much of what we do.

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