Fatigue

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A/P

The most likely cause of patients fatigue is {_unclear at this time}. However, we are considering overexertion, deconditioning, anemia, lung disease, medications, depression, thyroid issues, vitamin deficiencies.

Based off patient history and physical exam pt is likely experiencing [_secondary fatigue is caused by an underlying medical condition and may last one month or longer, but it generally lasts less than six months. Physiologic fatigue is an imbalance in the routines of exercise, sleep, diet, or other activity that is not caused by an underlying medical condition and is relieved with rest. Chronic fatigue lasts longer than six months and is not relieved with rest]

Medications are a possibility of the patients fatigue, medication review shows {_} as a possible cause.

Discussed with patient that deconditioning is a likely cause

We also talked about depression and how it can lead to fatigue

Cardiovascular causes are unlikely as patient declines chest pain, Sobr, palpitations.

Patient denies any food intolerances

Patient denies any environmental exposures

Patient denies any current substance use

No infectious etiologies likely today

-CBC

-CMP

-TSH

-Vit-D

-Vit-B12

– ANA

– Morning Cortisol

– ACTH

-Exercise therapy was recommended occluding 150 minutes of exercise per week with regular moderate aerobic activity

-Patient was also advised to get 7 to 8 hours of sleep per night

-We will plan on following up on lab results and exercise regimen in 2 weeks

-Can consider Echo for further evaluation to ensure cardiac causes are ruled out if the above is normal

-Consider additional workup with imaging if the above exercise and sleep recommendations do not improve symptoms

-Can consider sleep study on follow up if no improvement in symptoms

The above recommendations are from AAFP July 2023 journal issue on evaluating fatigue.

HPI

Fatigue:

Patient reports fatigue for {_}

Patient reports fatigue relived by rest: yes {_} no

Is patient getting refreshing sleep: yes {_} no

Any orthostatic intolerance: yes {_} no

Any recent illness: yes {_} no

Any new medications: {_}

Patients specific symptoms: {_}

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