March 17, 2015
Today, my first patient asked me my most dreaded question, “Doctor, why am I always tired?” Tired, fatigued, exhausted and lacking energy are among the many dreaded symptoms I hear almost every day. Why do I dread this complaint? Fatigue is a symptom of almost every disease known to mankind!
In the article titled “Differential Diagnosis” (1/18/11), I reviewed how doctors formulate a list of possible causes for an illness, arrange those possible causes by probability of occurrence and potential for doing harm and methodically work through the list until an appropriate diagnosis is made. The differential diagnosis for fatigue starts with “A” and ends with “Z”. There are common causes of fatigue: anemia; thyroid disease; sleep disorders including sleep apnea; depression; stress reaction; physical exhaustion; diabetes; hypertension; chronic fatigue syndrome; and COPD are but a few.
A typical office visit is divided into three parts: the interview, the exam and the planning stage. The interview for the complaint of fatigue is often exhaustive. The interview can also be frustrating as fatigue influences every part of a person’s life. Doctors work with an interview tool called the “review of systems” (ROS). The ROS is comprised of 14 organ systems with specific questions relating to each of those systems. When dealing with a patient who suffers from fatigue, all 14 systems must be explored and most patients have complaints in the majority of systems. The doctor is often left with the “Chicken vs. the Egg” conundrum.
Now, do you understand why I dread this question? To make matters worse, the physical exam seldom provides an answer requiring laboratory and other diagnostic testing. While I am a puzzle solver and very experienced at solving this puzzle, each patient’s puzzle is unique and requires a novel solution and treatment approach.
So, when you complain of fatigue, and most of us will during our lifetime, recognize that the “Why” may be difficult to find, requiring extensive searching through your history, your physical exam and extended testing. Be prepared for some frustration. Be opened-minded about the various possibilities. Recognize that one of the differential diagnoses is psychological and do not get offended if your doctor suggests you see a psychologist for testing. At least, the psychologist’s tests don’t involve needles and KY Jelly!
Before seeing your doctor, ask the why, what, how, when and where questions about your fatigue. Go through your own ROS. In doing so, you may solve your own puzzle. The more you question yourself, the easier it will be for you to answer your doctor’s questions. While I am trained to solve puzzles by myself, it is easier if I have help. Bring your significant other; he or she often has insights that are helpful.
One last request, if you could have a run of the mill anemia or thyroid problem, it would make my life easier! Now, the big question for today is why am I, your doc, so tired?