Assessment of Individual with Fatigue
The following is a basic outline for the initial intake and assessment of someone with a condition related to fatigue. This can apply to Chronic Fatigue Syndrome, fibromyalgia, or any other case of fatigue with unknown cause. It is possible for case history to lead to factors not in the summary. This is only intended as a basic outline, to be modified as needed - not a rigid protocol.
Subjective - Review of Symptoms
Current Symptoms
The following is a brief outline - much more can be covered in a visit - depending upon what direction the case points to.
- Energy level throughout the day. Any time feel better or worse?
- Sleep. Need to sleep/nap in the middle of the day? Insomnia? If so can't fall asleep insomnia or waking up in the middle of the night?
- Review of systems
- Digestive system: gas, bloating, pain, tenderness on palpation
- Immune system. Often get sick? Frequent use of antibiotics? Never get sick (can be a sign of depressed immune system)
- Musculoskeletal: any aches or pains? In joints? Muscles? tender point Vs trigger point
- Cardiovascular symptoms?
- G/U symptoms. UTI's infections?, kidney pain? Frequent urination?
- Women: PMS or other illness associated with reproductive system, or any symptoms with cycle (if not current, then past?)
- Respiratory system. Coughs, bronchitis, swollen lymph nodes?
- Nervous system
- Emotional stress - emotional trauma, losses, grief, anger, worry, fear?
- Lifestyle and diet. Any special diet? Any foods currently avoiding and why? Review diet for common allergens (wheat, dairy, corn, soy are at top of list - although more). Lifestyle - especially stress or long work hours? Stress at home? Healthy environment at home?
- Current medications or supplements
- Constitutional signs: Hot/Cold, stagnation, constriction, dampness. See page on herbal medicine for more information. This assessment is very important to determine what herbs are best for the individuals, as part of treating the person rather than the disease.
Past medical history
- Childhood illness or infections
- Dental work, infections?
- History of antibiotic use
- Reoccurring past infections - even if doesn't have it anymore (may be a sign that the body is not longer producing that symptoms, as the "disease" has moving deeper inside the body).
- Emotionally traumatic events
- Any past surgeries including tonsillectomy, appendectomy, gallbladder?
- Potential toxic exposures?
- Health history time line: Taking note of all symptoms past and present and charting it out in order to progression. Often people seem to have different diseases at different times, when in fact it's the same disease process that never goes away, but rather just presents as different symptoms. Symptoms may be very different, effecting various systems, so this may not be obvious at first
Objective - Lab Work and Physical Finding
Blood tests
All blood work should be reviewed carefully. Official reference ranges are often very large and have more to do with establishing norms for official diagnosis categories, then determining overall health.
Very sick people may have "normal" blood work. However on closer inspection labs are often not in optimal range. For example, the official reference range for monocytes may go up to 13%, but optimally it should be less than 7%. Anything higher can indicate a chronic infection.
Typically the most relevant blood work includes:
- CBC and differential: White Blood Cell count (WBC) and differential may be very important, as infections (acute or hidden chronic ones) can be a major cause of fatigue
- Thyroid hormone: TSH, T3, T4, thyroid antibodies
- Anemia? Iron, TIBC, Ferritin in addition to CBC (RBC, hemoglobin, hematocrit)
- Blood sugar: glucose, HgA1c
Functional labs
There are specialty labs typically used by "alternative" practitioners: NDs, functional medical doctors, DC, etc. They are generally not covered by insurance. Although at times valuable, it's important to order them carefully or else it turns into a large out of pocket expense. It's also possible for patient to end up with a large collection of functional lab tests that do not show where the problem is - when the problem could be more easily seem through a comprehensive history and some basic in office exam.
Partial list of some functional labs tests:
- Hormone tests
- Stool test for parasites, allergens, dysbiosis, inflammation
- Food allergies
- Toxicity: porphyrin tests, metals
- Other labs tests, amino acids, organic acid
Physical signs
- Bennett and chapman reflux point.
- Tongue diagnosis. fingernails, skin, visual signs
- Muscle testing (go here for more information)
Sample case history
Link to sample case of client with Chronic Fatigue Syndrome