Fatigue

HISTORY:

Fatigue for ‍ ‍hoursdays

Severity: ‍mildmoderatesevere, ‍minimal impact on daily activities

Pattern: ‍persistentintermittent, worse during the ‍day

Worsening factors: ‍noneexertionmental activitystress

Treatments tried: ‍none, ‍effectiveineffective

‍insomnia

‍anxiety

‍depression

‍dizziness

‍loss of appetite

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍abdominal pain



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Fatigue due to psychosocial stressors ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍TSH, ‍electrolytes, ‍creatinine, ‍glucose, ‍LFTs, ‍vitamin B12, ‍folate, ‍ferritin, ‍iron studies, ‍CRP, ‍β-hCG, ‍mono spot test, ‍EBV antibodies, ‍HIV, ‍syphilis, ‍HBsAg, ‍hepatitis C

- Urinalysis

- ECG

- Chest X-ray

- Sleep study

- Lifestyle modifications: ‍healthy diet, ‍regular exercise, ‍good sleep hygiene, ‍stress management techniques

- ‍Antidepressants

- ‍Stimulants

- ‍Iron supplements

- Multi-vitamins

- Referral to psychologist

- Referral to sleep specialist

- Referral to endocrinologist

- Follow-up in ‍ ‍weeksmonths

- Return if fatigue worsens or if new symptoms develop such as weight loss, fever, or persistent sleep disturbances