Investigation of Fatigue in Primary Care

Introduction

A state of physical or mental exhaustion that makes it difficult or impossible to start or continue an activity is fatigue. It may impair one's mental clarity, physical coordination, sense of judgment, and ability to make decisions. If expressed in simple terms, patients who experience fatigue typically characterize it as being tired or drained. Fatigue is the sense of being too exhausted to start doing normal tasks. The sensation can occur during or after the activities.

Although fatigue is a common occurrence, it can also be a sign of serious illnesses or other diseases. In the primary care practice, complaints of coughing is more prevalent and frequent than complaints of fatigue. Fatigue is a common primary complaint among patients who visit primary care physicians. Most consultations for fatigue are one-time visits with no follow-up.

How Fatigue Is Relevant to Primary Care Practice?

An often-presented complaint in general practice, fatigue can have a severe impact on a patient's ability to function at work and in their personal and familial connections. As a result of its links with biophysical, psychological, and social issues, it frequently presents a diagnostic challenge with a range of differential diagnoses. According to international studies, one in four patients in family medicine complains of being tired, with exhaustion accounting for 6.5 percent of encounters as the primary cause and 19 percent as a secondary cause. Fatigue is also common in the young adult and pediatric populations.

What Is the Classification of Fatigue?

• Classification of Fatigue Based on Time Interval

  • Acute Fatigue - The time duration is one month or less than one month.

  • Subacute Fatigue - It lasts for one to six months.

  • Chronic Fatigue - It lasts for more than one month.

• Classification of Fatigue Based on Cause or Etiology

  • Physiologic Fatigue - It is brought on by an imbalance in daily routines such as sleep, exercise, nutrition, or other activities unrelated to an underlying medical condition and is relieved by rest.

  • Secondary Fatigue- It is brought on by an underlying medical illness.

What Methods Are Used in Primary Care Settings to Evaluate Fatigue?

• Patient History - Information regarding the type of fatigue (physical or mental), its duration (acute, subacute, or chronic), its onset (sudden or progressive), its recovery period (short or long), and the patient's typical level of physical activity (sedentary or active) can all help identify the underlying cause. Taking the history of the patient is important for separating chronic fatigue from chronic fatigue syndrome. Chronic fatigue syndrome presents with a fast onset, and the recovery phase lasts for several hours or days. A lot of people who suffer from chronic fatigue are just "out of shape" and will benefit from exercise therapy.

• Physical Examination - It shows signs of organ-based disease. Pallor (anemia or malignancy), lymphadenopathy (malignancy), goiter (thyroid illness), murmurs (endocarditis), and edema (cardiac failure, liver disease) are physical examination signs that suggest the presence of underlying somatic diseases (cardiac failure, liver disease).

• Drugs and Hazardous Exposures - Drug usage should be assessed. Long-acting antihistamines, corticosteroids, neuroleptics, antiarrhythmics, antidepressants, and antihypertensives (such as Clonidine, -Methyldopa, and beta-blockers), as well as herbal medicines, are among the typical pharmaceuticals frequently disregarded as reasons of fatigue. Fatigue may be a symptom of toxicity in patients with renal or hepatic impairment (for example, increased Digoxin or anticonvulsant levels). It is important to take into account both acute and chronic harmful environmental exposures (such as those to carbon monoxide, lead, mercury, and arsenic).

• Psychiatric Evaluation - The majority of patients who present to primary care with unexplained fatigue have depression. Panic disorder and somatization disorder are the other psychiatric disorders. It is also vital to ask specific questions about drug use and alcohol consumption.

• Evaluation for a Sleep Disorder - Parasomnias, excessive drowsiness, and sleep apnea are all very prevalent. A new tool, the sleep disorders questionnaire, may have a high sensitivity and specificity (95 percent and 87 percent, respectively) when used in the primary care environment, according to preliminary results.

What Laboratory Tests Help Diagnose Fatigue in Primary Care?

In order to rule out dangerous and frequent underlying disorders and to identify people with an iron deficiency, which is a common and easily treatable cause of fatigue, subsequent laboratory testing should be recommended by primary care physicians. Unfortunately, laboratory testing is rarely useful in the absence of a positive history or physical examination.

Even among patients who report fatigue, minor abnormalities are commonly seen in the test results, the majority of which are unrelated to exhaustion. Fatigue can result from an iron shortage, even in the absence of anemia, and treating such patients with iron seems to help in many of these situations. Based on the patient's medical history and the physical results, additional directed tests (such as HIV antibody testing) should be taken into consideration. Below is the list of preliminary tests recommended for patients who complain of fatigue:

• Total blood count.

• LFT or liver function test.

• Thyroid test (T3, T4, and TSH).

• Kidney function test.

• Electrolyte test.

• ESR (erythrocyte sedimentation rate).

• Blood glucose, urine analysis, and inflammatory marker test.

• Urine test in women of childbearing age.

How Is Fatigue Managed?

Both non-pharmacological and pharmacological methods are used to treat fatigue.

• Pharmacological Method - In patients in whom depression is suspected in the absence of microbial pathology, a six-week trial of selective serotonin reuptake inhibitors (SSRIs) (for example, Fluoxetine, and Sertraline) may be considered. Overusing hypnotic drugs, such as antihistamines (such as Hydroxyzine), to promote sleep is a frequent mistake. The patient should be educated by the primary care physicians that fatigue is a symptom that can be managed non-pharmacologically, with pharmacotherapy being prescribed only when non-pharmacological interventions are deemed ineffective.

• Non-Pharmacological Method - Exercise therapy and good sleep hygiene should be given to all patients irrespective of the cause of fatigue. In people with chronic fatigue syndrome, cognitive behavioral treatment has shown positive results. Patients should be educated that complete recovery from fatigue is possible with support and counseling.

Conclusion

Primary care physicians are most commonly the first people who come into contact with patients who report fatigue as their primary complaint. Treating fatigue requires a multidisciplinary approach. Primary care physicians should think about referring the patient to a specialist if there are secondary organic causes of fatigue that need to be handled at an expert level. Patients with mental illnesses should be considered for a prompt psychiatric referral.