Fatigue as the Chief Complaint–Epidemiology, Causes, Diagnosis, and Treatmentという文献
Center for General Practice, Faculty of Medicine, University of Münster; Department of General Practice, University of Marburg.
Results:
Fatigue can be due to any of a broad spectrum of diseases, including decompensation of already known conditions.
Sleep disorders and sleep-related disorders of breathing, depression (18.5%), and excessive psychosocial stress are the most common causes of persistent fatigue.
Previously undiagnosed cancer is a rare cause, accounting for only 0.6% of cases (95% confidence interval [0.3; 1.3]).
Anemia and other organic causes are rare as well (4.3% [2.7; 6.7]).
Investigations beyond the history, physical examination, and simple laboratory tests are needed only in the presence of additional symptoms or findings.
If the diagnosis remains unclear, watchful waiting and regularly scheduled follow-up help prevent an excessive focus on somatic causes, leading to overdiagnosis.
Irrespective of specific causes, psychoeducative and psychotherapeutic approaches should be discussed with the patient, as well as an individually adapted exercise program.
Abstract
Fatigue is a common symptom in primary care with many causes ranging from benign to life threatening. Appropriate evaluation and management are guided by the patient's history, which provides valuable clues as to the source of the patient's symptoms. Ultimately a diagnosis may not be identified for many patients presenting with fatigue, and in these patients management is the most challenging. This article offers guidance in the management of patients presenting with fatigue including key aspects of the patient's history of present illness, the building of a differential diagnosis, rational evaluation in a patient with a nondiagnostic history, and management in the setting of a nondiagnostic work-up.
Causes of fatigue
Murtagh provides a helpful framework for understanding the aetiology by categorising the causes of fatigue into probability diagnoses, serious disorders not to be missed and pitfalls.15
Probability diagnoses include stress and anxiety, depression, viral/post-viral infection and sleep-related disorders.
Serious disorders include malignancy, cardiac arrhythmias, cardiomyopathy, anaemia, bacterial infection, haemochromatosis, human immunodeficiency virus (HIV) infection and hepatitis C. Common pitfalls include coeliac disease, pregnancy, renal failure and metabolic disturbances.
Medication-related side effects are another key consideration. There is a strong relationship between fatigue (especially if prolonged) and psychological disorders.11,16–18
Psychosocial causes of fatigue (eg. depression and anxiety) have been shown to be the most common non-somatic diagnoses made.8–10,19
The prevalence of formal diagnoses made in patients presenting with fatigue in primary care is not clearly established. Studies vary widely in methodology (definitions and inclusion criteria), making comparison difficult. In a recent Dutch cohort study of patients with fatigue, more than half had not received a diagnosis after 12 months follow up and only 8.2% were diagnosed with somatic pathology (eg. anaemia, thyroid disease, diabetes).19
Other studies have demonstrated significantly higher rates of organic disease of 25–50% of all patients.9,10,13 These discrepant findings are probably due to differing methods of classifying fatigue and somatic diagnoses.
Thus, although fatigue may be related to a variety of medical and psychological causes, it often remains unexplained. It has been shown that for close to half (43%) of patients presenting to their GP with fatigue, the final diagnosis will be ‘tiredness’.5
