The Low Yield of Physical Examinations and Laboratory Investigations of Patients with Chronic Fatigue

doi:10.1097/00000441-199005000-00005

The American Journal of the Medical Sciences

Volume 299, Issue 5, May 1990, Pages 313-318

https://doi.org/10.1097/00000441-199005000-00005 Get rights and content

ABSTRACT

Fatigue is a common symptom but guidelines for its appropriate evaluation are lacking. The authors prospectively studied 100 adults with a chief complaint of fatigue lasting at least 1 month in order to determine the diagnostic contribution of physical examinations and laboratory investigations. The evaluations were performed in the specialized clinic of a faculty practice. Physical examinations produced diagnostic information in 2% of patients, and laboratory investigations elucidated the cause of fatigue in 5% of patients. Structured follow-up evaluations after an average interval of 10 months failed to reveal any new organic causes for the fatigue symptom. Minor laboratory abnormalities were relatively common but did not contribute to the diagnostic process and did not seem to influence the clinical outcome. The authors conclude that the traditional medical evaluation of patients complaining of chronic fatigue has a low yield in discovering treatable physical disorders.

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Cited by (82)

Chronic fatigue: What investigations? And what for?
2023, Revue de Medecine Interne
La fatigue chronique est une plainte fréquente, exprimée à tous les niveaux du système de soin. Elle est perçue comme invalidante dans une proportion élevée de cas, et les internistes sont fréquemment sollicités pour en trouver « la » cause. Il faut savoir axer la démarche diagnostique étiologique d’un état de fatigue inexpliqué sur la recherche attentive d’indices plus spécifiques par l’interrogatoire et l’examen clinique. Il faut reconnaître la place limitée des examens complémentaires en dehors des paramètres biologiques de base. Des échelles d’évaluation simples peuvent s’avérer utiles aux diagnostics étiologiques et différentiels de la fatigue. Le syndrome de fatigue chronique (SFC), dans l’état actuel des connaissances, ne nous semble pas pouvoir être considéré comme une entité pathologique spécifique distincte des états de fatigue chronique idiopathique, et ne dispose pas de biomarqueurs validés. Il est important de savoir qu’un état d’asthénie chronique relève souvent de plusieurs facteurs étiologiques intriqués (biologiques, psychologiques et sociaux), à classer comme prédisposants, précipitants et d’entretien. L’épreuve métabolique et cardiorespiratoire d’effort a une place majeure dans l’évaluation et la prise en charge, comme préalable à un réentraînement ou une activité physique adaptée (APA) personnalisés, qui sont les traitements de choix de la fatigue chronique.
Chronic fatigue is a frequent complaint, expressed at all levels of the healthcare system. It is perceived as disabling in a high proportion of cases, and internists are frequently called upon to find “the” cause. The etiological diagnostic approach of an unexplained state of fatigue relies on the careful search for more specific clues by questioning and clinical examination. It is necessary to recognize the limited place of complementary examinations apart from the basic biological parameters. Simple rating scales can be useful in the etiological and differential diagnosis of fatigue. Chronic fatigue syndrome (CFS), in the current state of knowledge, cannot be considered as a specific pathological entity distinct from idiopathic chronic fatigue states, and does not have validated biomarkers. It is important to know that a state of chronic asthenia often results from several intricated etiological factors (biological, psychological and social), to be classified as predisposing, precipitating and perpetuating. The metabolic and cardiorespiratory exercise test has a major place in the assessment and management of fatigue, as a prerequisite for personalized retraining or adapted physical activity (APA), which are the treatments of choice for chronic fatigue.
Approach to Fatigue: Best Practice
2021, Medical Clinics of North America
Citation Excerpt :
Owing to the very broad, and potentially fatal, differential diagnoses that can present as fatigue, a rational approach to diagnosis is critical. Performing a battery of diagnostic tests is unlikely to assist with diagnosis,5,6 highlighting the importance of forming an appropriately prioritized patient-centered differential diagnosis through a comprehensive history of presenting illness, review of systems, and physical examination.5,6 Although fatigue is a common complaint, it may be confused with sleepiness as patients often present with a vague complaint of being “tired” or “exhausted".7
Adolescent fatigue, POTS, and recovery: A guide for clinicians
2014, Current Problems in Pediatric and Adolescent Health Care
Citation Excerpt :
Testing for POTS will be discussed in detail in a later section. Additional laboratory or imaging studies have not been shown to be useful in making the diagnosis of CFS; however, they may be obtained if deemed necessary given the information obtained through history and physical examination.24 The diagnosis of unexplained chronic fatigue cannot be made if patient has an active medical condition that explains chronic fatigue such as hypothyroidism, primary sleep disorder, or a medication side effect.
Many teenagers who struggle with chronic fatigue have symptoms suggestive of autonomic dysfunction that may include lightheadedness, headaches, palpitations, nausea, and abdominal pain. Inadequate sleep habits and psychological conditions can contribute to fatigue, as can concurrent medical conditions. One type of autonomic dysfunction, postural orthostatic tachycardia syndrome, is increasingly being identified in adolescents with its constellation of fatigue, orthostatic intolerance, and excessive postural tachycardia (more than 40 beats/min). A family-based approach to care with support from a multidisciplinary team can diagnose, treat, educate, and encourage patients. Full recovery is possible with multi-faceted treatment. The daily treatment plan should consist of increased fluid and salt intake, aerobic exercise, and regular sleep and meal schedules; some medications can be helpful. Psychological support is critical and often includes biobehavioral strategies and cognitive–behavioral therapy to help with symptom management. More intensive recovery plans can be implemented when necessary.
Fatigue
2014, Medical Clinics of North America
Citation Excerpt :
Often one of the most challenging aspects of evaluating a patient with nonspecific fatigue characterized by a generalized lack of energy is deciding on the appropriate scope of laboratory evaluation. Although in general the data are sparse, it seems that laboratory studies only rarely reveal the cause of a patient’s fatigue; diagnosis is made after laboratory evaluation in approximately 5% of cases.2 Standard recommendations regarding the initial, rational laboratory evaluation include complete blood count, a basic metabolic panel, hepatic function testing, an erythrocyte sedimentation rate, thyroid dysfunction screening with a thyroid-stimulating hormone, and pregnancy testing in women of childbearing age.
Naturopathic Physical Medicine Approaches to General Health Enhancement and Specific Conditions
2008, Naturopathic Physical Medicine
An audit of clinically relevant abnormal laboratory parameters investigating athletes with persistent symptoms of fatigue
2007, Journal of Science and Medicine in Sport
Citation Excerpt :
This study, and ours, is in agreement that there is a low yield from blood tests in athletes presenting with fatigue. These findings are remarkably similar to studies of patients presenting with chronic fatigue in general practice.9–11 It also highlights the importance of the clinical history in the diagnosis of fatigued athletes,3 and the potential role of other parameters e.g. mood state questionnaires.5
The aim of this audit was to assess the yield of a selection of laboratory tests as part of the clinical assessment of the fatigued athlete. Clinical charts and blood test results of fifty consecutive athletes who presented with the primary complaint of fatigue were retrospectively reviewed. Blood tests results reviewed were: haematology (haemoglobin, red cell count, mean cell volume, mean cell haemoglobin content, platelets, white cell count, differential white cell count); erythrocyte sedimentation rate; serum biochemistry (urea, creatinine, electrolytes, urate, glucose, liver function tests, albumin, globulin); blood iron status (serum iron, total iron binding capacity, percent transferring saturation, and ferritin concentration); thyroid stimulating hormone; and immune measures (Epstein–Barr virus serology, cytomegalovirus serology). We identified only 3 abnormal results that contributed to the diagnosis of medical disease as a cause for fatigue. Laboratory testing identified 2 fatigued female athletes with serum ferritin concentration between 15 μg L⁻¹ and 20 μg L⁻¹ plus two of the other criteria of iron concentration (serum iron <10 μmol L⁻¹, iron binding capacity >68 μmol L⁻¹, or transferrin saturation <15%). We concluded that the yield from a selection of blood tests investigating fatigued athletes was low. Future study is needed to further define the role of laboratory testing and to study whether low iron stores in the absence of anaemia is related to symptoms in fatigued athletes.

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The authors are indebted to the nursing and clerical staff of the General Medicine Outpatient Module at the University of Connecticut Health Center. Farmington. for their help throughout this study.

This paper has been presented. in part. at the National Meeting of the Society for General Internal Medicine. Washington. D.C., April 28. 1988.

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Original ManuscriptsThe Low Yield of Physical Examinations and Laboratory Investigations of Patients with Chronic Fatigue

ABSTRACT

Lancet

Chronic mononucleosis syndrome

South Med J

Persisting illness and fatigue in adults with evidence of Epstein-Barr virus infection

Ann Int Med

Epstein-Barr virus and persistent malaise

Lancet

Evidence for active Epstein-Barr virus infection in patients with persistent, unexplained illnesses: Elevated antiearly antigen antibodies

Ann Int Med

Chronic fatigue possibly related to Epstein-Barr virus-Nevada

MMWR

A cluster of patients with a chronic mononucleosis-like syndrome. Is Epstein-Barr virus the cause?

JAMA

Frequency of’chronic-active Epstein-Barr virus infection’ in a general medical practice

JAMA

EB or not EB-that is the question

JAMA

Chronic fatigue syndrome: A working case definition

Ann Int Med

Office Visits to Internists

The clinical significance of tiredness

Can Med Assoc J

Original Manuscripts
The Low Yield of Physical Examinations and Laboratory Investigations of Patients with Chronic Fatigue