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Undifferentiated Fatigue — A Systematic Diagnostic Approach
Consultant-physician-depth guide to the diagnostic approach to the patient with chronic fatigue. Covers the three functional categories (physiological — sleep deprivation, overwork, deconditioning, pregnancy, post-viral; psychological — depression, anxiety, chronic stress, burnout, grief; physical or systemic — anaemia, thyroid disease, diabetes, cardiac failure, sleep apnoea, CKD, hepatic failure, COPD, malignancy, autoimmune disease, chronic infection, drug-related, nutritional, Addison disease, narcolepsy, myasthenia gravis), the focused history with the PHQ-2 and GAD-2 mood screens, the systematic examination with the bedside discriminators (pallor, koilonychia, clubbing, hyperpigmentation, the postural blood pressure, the thyroid), the two-tier investigation framework (Tier 1 — FBC, ferritin, B12, folate, U and E, LFTs, TFTs, CRP, glucose and HbA1c, vitamin D, urinalysis, CXR, ECG, pregnancy test; Tier 2 — autoimmune screen, HIV and hepatitis serology, troponin and BNP, sleep study, short Synacthen), the principle of avoiding over-investigation, the management of the cause and of the unexplained fatigue (reassurance, sleep hygiene, graded activity, CBT, medication review, depression treatment, planned review), and the specific guidance on ME and CFS (NICE 2021 NG206 — the withdrawal of graded exercise therapy, the pacing and energy management) and post-COVID condition (long COVID). Structured for FRACP DWE and DCE, MRCP and ABIM.
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