The bell chimes and it’s the next station – you have a 33-year-old male who presents with fatigue for several months. He has no other medical history. ENTER THE ROOM.

Do you want to pull your hair out? Bite your fingernails? HOLD ON! We’re here to help. Here’s a brief checklist to follow for your SOO (or SAMP) – we used this helpful CMAJ article to help create a SOO tool for you.

“Doc, what could have caused my fatigue?â€

Remember to keep your differential broad in your SOO. Think about the following common causes:

• Infectious (Viral illness, EBV, HIV, hepatitis)
• Endocrine (TSH, Diabetes, Addison’s)
• Hematologic (Iron deficiency anemia, autoimmune)
• Malignancy
• Medication side effects
• GI (Liver disease, primary biliary cirrhosis, Celiac)
• Cardiorespiratory (Heart disease, CHF, COPD)
• Autoimmune (Rheumatoid arthritis)
• Neurologic (CVA, multiple sclerosis, myasthenia gravis, Parkinson’s disease, ALS)
• Mood/Depression

Based on the above list, some questions you may consider asking:

• Did your symptoms come on suddenly or have they been progressively getting worse?
• Have you noticed changes to your weight? If so, how much and over what period of time?
• Do you have black stools or rectal bleeding?
• Do you have abdominal discomfort? Nausea? Vomiting?
• Have you noticed any blood in your urine? Vaginal bleeding (for female patients)?
• Do you have a fever? A sore throat? A cough?
• Are you short of breath?
• Are you taking any prescription or OTC medications?
  • e.g., antihistamines, corticosteroids, neuroleptics, antiarrhythmics, antidepressants, antihypertensives, herbal remedies
• Where do you live? Have you had a change in your job recently?
  • e.g., carbon monoxide, lead, mercury, arsenic
• Have you had any panic attacks, periods of low mood, etc.?
• Do you drink alcohol? If so, how much do you drink on a weekly basis?
• Do you use any substances to help you cope?
• Do you nap throughout the day?
• Do you feel drowsy when driving?
• Do you feel refreshed when you wake up?
• Has anyone ever told you that you snore?
• Has your partner ever complained of abnormal movements when you are sleeping, sleep walking, etc.?
• Do you have a family history of cancer? Autoimmune conditions? Cardiac issues?

Do not forget to FIFE!

“Doc, I read about chronic fatigue – how do I know if I have that?”

You have chronic fatigue if your fatigue has lasted more than 6 months and you have at least four of the following symptoms:

• Subjective memory impairment
• Tender lymph nodes
• Muscle pain
• Joint pain
• Headache
• Unrefreshing sleep
• Post-exertional malaise (> 24 hr)

On a SAMP, what investigations do you propose? Well… in many cases, “none†is an acceptable answer (see CFPC fatigue objectives). 

BUT, as an FYI for prolonged fatigue… CMAJ suggests:

• Hb
• Ferritin
• TSH
• ESR, CRP
• Urea, K+, Na+, Mg, and creatinine
• Serum calcium and phosphate
• AST, ALT
• Hba1c/fasting glucose
• CK
• Urinalysis for protein, blood, and glucose
• Urine pregnancy test (in women of childbearing age)
• Sleep study
• Infectious disease workup (hepatitis, HIV, VDRL)

Written by Maria Veinberg. Reviewed by Dr. Prokubovskaya & Dr. Premji.