Fatigue occurs most often as part of a symptom complex, but even when it is the sole or main presenting symptom, fatigue is one of the most common symptoms.
Fatigue is difficulty initiating and sustaining activity due to a lack of energy and accompanied by a desire to rest. Fatigue is normal after physical exertion, prolonged stress, and sleep deprivation.
Patients may refer to certain other symptoms as fatigue; differentiating between them and fatigue is usually, but not always, possible with detailed questioning.
Weakness Weakness Weakness is one of the most common reasons patients present to primary care clinicians. Weakness is loss of muscle strength, although many patients also use the term when they feel generally... read more , a symptom of nervous system or muscle disorders, is insufficient force of muscular contraction at maximum effort. Disorders such as myasthenia gravis Myasthenia Gravis Myasthenia gravis involves episodic muscle weakness and easy fatigability caused by autoantibody- and cell-mediated destruction of acetylcholine receptors. It is more common among young women... read more and Eaton-Lambert syndrome Neurologic paraneoplastic syndromes Paraneoplastic syndromes are symptoms that occur at sites distant from a tumor or its metastasis. Although the pathogenesis remains unclear, these symptoms may be secondary to substances secreted... read more can cause weakness that worsens with activity, simulating fatigue.
Dyspnea Dyspnea Dyspnea is unpleasant or uncomfortable breathing. It is experienced and described differently by patients depending on the cause. Although dyspnea is a relatively common problem, the pathophysiology... read more on exertion, an early symptom of cardiac and pulmonary disorders, can decrease exercise tolerance, simulating fatigue. Respiratory symptoms usually can be elicited upon careful questioning or develop subsequently.
Somnolence, a symptom of disorders causing sleep deprivation (eg, allergic rhinitis Allergic Rhinitis Allergic rhinitis is seasonal or perennial itching, sneezing, rhinorrhea, nasal congestion, and sometimes conjunctivitis, caused by exposure to pollens or other allergens. Diagnosis is by history... read more , esophageal reflux Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more , painful musculoskeletal disorders, sleep apnea Obstructive Sleep Apnea Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more , severe chronic disorders), is an unusually strong desire to sleep. Yawning and lapsing into sleep during daytime hours are common. Patients can usually tell the difference between somnolence and fatigue. However, deprivation of deep nonrapid eye movement sleep can cause muscle aches and fatigue, and many patients with fatigue have disturbed sleep, so differentiating between fatigue and somnolence may be difficult.
Fatigue can be classified in various temporal categories, such as the following:
Recent fatigue: < 1 month duration
Prolonged fatigue: 1 to 6 months duration
Chronic fatigue: > 6 months duration
Chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied... read more is one cause of chronic fatigue. There are now 2 other terms for chronic fatigue syndrome—myalgic encephalomyelitis and systemic exertion intolerance—although there is no clear delineation between these at this time. Patients with COVID-19 COVID-19 COVID-19 is an acute, sometimes severe, respiratory illness caused by a novel coronavirus SARS-CoV-2. COVID-19 was first reported in late 2019 in Wuhan, China and has since spread extensively... read more may have symptoms that last for weeks or even months, which is known as "long COVID" or "long-haul COVID" and resembles postviral fatigue (and can be called post-viral fatigue syndrome) and chronic fatigue syndrome.
Etiology of Fatigue
Most serious (and many minor) acute and chronic illnesses produce fatigue. However, many of these have other more prominent manifestations (eg, pain, cough, fever, jaundice) as the presenting complaint. This discussion focuses on disorders that can manifest primarily as fatigue.
The most common disorders manifesting predominantly as recent fatigue (lasting < 1 month) are
The most common causes manifesting predominantly as prolonged fatigue (lasting 1 to 6 months) are
The most common causes manifesting predominantly as chronic fatigue (lasting > 6 months) are
Myalgic encephalomyelitis/systemic exertion intolerance disease/chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied... read more
Postviral fatigue syndrome
Several factors commonly cause or contribute to a chief complaint of fatigue, usually prolonged or chronic fatigue (see table Some Factors Commonly Contributing To Prolonged Or Chronic Fatigue Some Factors Commonly Contributing To Prolonged Or Chronic Fatigue Fatigue occurs most often as part of a symptom complex, but even when it is the sole or main presenting symptom, fatigue is one of the most common symptoms. Fatigue is difficulty initiating... read more ).
Evaluation of Fatigue
Fatigue can be highly subjective. Patients vary in what they consider to be fatigue and how they describe it. There are also few ways to objectively confirm fatigue or tell how severe it is. History and physical examination focus on identifying subtle manifestations of underlying illness (particularly infections, endocrine and rheumatologic disorders, anemia, and depression) that can be used to guide testing.
History of present illness includes open-ended questions about what "fatigue" is, listening for descriptions that could suggest dyspnea on exertion, somnolence, or muscle weakness. The relationships between fatigue, activity, rest, and sleep should be elicited, as should the onset, time course and pattern, and factors that increase or decrease fatigue.
Review of systems should be thorough because potential causes of fatigue are so numerous and diverse. Among important nonspecific symptoms are fever, weight loss, and night sweats (possibly suggesting cancer, a rheumatologic disorder, or an infection). Menstrual history is obtained in women of child-bearing age. Unless a cause is evident, patients should be asked questions from screening questionnaires for psychologic disorders (eg, depression, anxiety, drug abuse, somatoform disorders, domestic violence).
Past medical history should address known disorders. Complete drug use history should include prescription, over-the-counter, and recreational drugs.
Social history should elicit descriptions of diet, drug abuse, and the effect of fatigue on quality of life, employment, and social and family relationships.
Vital signs are checked for fever, tachycardia, tachypnea, and hypotension. General examination should be particularly comprehensive, including general appearance and examination of the heart, lungs, abdomen, head and neck, breasts, rectum (including prostate exam and testing for occult blood), genitals, liver, spleen, lymph nodes, joints, and skin. Neurologic examination should include testing of, at a minimum, mental status, cranial nerves, mood, affect, strength, muscle bulk and tone, reflexes, and gait. Usually if fatigue is of recent onset, a more focused examination will reveal the cause. If fatigue is chronic, examination is unlikely to reveal a cause; however, thorough physical examination is an important way to build rapport with the patient and occasionally is diagnostically helpful.
Chronic weight loss
Chronic fever or night sweats
Muscle weakness or pain
Serious nonfatigue symptoms (eg, hemoptysis, hematemesis, severe dyspnea, ascites, confusion, suicidal ideation)
Involvement of > 1 organ system (eg, rash plus arthritis)
New or different headache or loss of vision, particularly with muscle pains, in an older adult
Interpretation of findings
In general, a cause is more likely to be found when fatigue is one of many symptoms than when fatigue is the sole symptom. Fatigue that worsens with activity and lessens with rest suggests a physical disorder. Fatigue that is present constantly and does not lessen with rest, particularly with occasional bursts of energy, may indicate a psychologic disorder.
In the absence of red flag findings, a thorough history, physical examination, and routine laboratory testing (plus tests directed at specific findings—see Interpretation of Selected Findings in Evaluating Fatigue Interpretation of Selected Findings in Evaluating Fatigue Fatigue occurs most often as part of a symptom complex, but even when it is the sole or main presenting symptom, fatigue is one of the most common symptoms. Fatigue is difficulty initiating... read more ) should suffice for an initial evaluation. If test results are negative, watchful waiting is usually appropriate; if fatigue worsens or other symptoms and signs develop, the patient is reevaluated.
Several causes can be considered for patients with prolonged or chronic fatigue and selected other common or specific clinical findings.
Testing is directed at causes suspected based on clinical findings. If no cause is evident or suspected based on clinical findings, laboratory testing is unlikely to reveal a cause. Still, many clinicians recommend testing with the following:
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR)
Thyroid-stimulating hormone (TSH)
Chemistries, including electrolytes, glucose, calcium, and renal and liver tests
Creatine kinase (CK) is recommended if muscle pain or weakness is present. HIV testing and purified protein derivative (PPD) placement are recommended if the patient has risk factors. Chest x-ray is recommended if cough Cough in Adults Cough is an explosive expiratory maneuver that is reflexively or deliberately intended to clear the airways. It is one of the most common symptoms prompting physician visits. (See also Cough... read more or dyspnea Dyspnea Dyspnea is unpleasant or uncomfortable breathing. It is experienced and described differently by patients depending on the cause. Although dyspnea is a relatively common problem, the pathophysiology... read more is present. Other testing, such as for infections or immunologic deficiencies, is not recommended unless there are suggestive clinical findings.
Diagnosis of myalgic encephalomyelitis/systemic exertion intolerance disease/chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied... read more requires 2 of the following:
Chronic fatigue that affects daily function, is not relieved by rest, and is not explained by clinical findings or abnormal findings on the laboratory tests mentioned above
For systemic exertion intolerance disease/chronic fatigue syndrome, postexertional malaise and unrefreshing sleep, as well as either cognitive impairment or orthostatic intolerance
For myalgic encephalomyelitis/chronic fatigue syndrome, the presence of ≥ 4 of the following: sore throat, unrefreshing sleep, difficulty with concentration or short-term memory, myalgias, multiple joint pains without joint swelling, new or different headaches, and tender cervical or axillary nodes
Treatment of Fatigue
Treatment to lessen fatigue is directed at the cause. Patients with myalgic encephalomyelitis/systemic exertion intolerance disease/chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied... read more and idiopathic chronic fatigue are treated similarly. They should be told clearly that the etiology is presently unknown. Treatment is more often successful if the practitioner is patient and nonjudgmental and acknowledges the real effects of fatigue. Potential treatments include physical therapy (eg, graded exercise therapy) and psychologic support (eg, cognitive-behavioral therapy). Focusing on improving sleep and relieving pain may also help. Goals include returning to work and maintaining normal activity levels.
Fatigue is more often the first symptom of a disorder in older patients. For example, the first symptom of pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more in an older woman may be fatigue rather than pulmonary symptoms. The first symptom of other disorders, such as giant cell arteritis Giant Cell Arteritis Giant cell arteritis involves predominantly the thoracic aorta, large arteries emerging from the aorta in the neck, and extracranial branches of the carotid arteries. Symptoms of polymyalgia... read more , may also be fatigue in an older patient. Because serious illness may become apparent soon after sudden fatigue in older patients, the cause should be determined as quickly as possible. Fatigue is also somewhat more likely to be caused by giant cell arteritis or another serious physical disorder in older adults.
Fatigue is a common symptom.
Fatigue caused primarily by a physical disorder increases with activity and lessens with rest.
Laboratory testing is low yield in the absence of suggestive clinical findings.
Successful treatment is more likely if the practitioner is patient and understanding.