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symptom.fatigue.v1

Chronic fatigue (outpatient symptom triage)

symptomchronicundifferentiatedadultgeriatricoutpatient
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym wave-14 (2026-05-14) — symptom-workup template clones from symptom.constipation.v1 (wave-11), symptom.fuo.v1, symptom.anemia-workup.v1. Engine scope: chronic fatigue (≥6 mo) outpatient triage + cause stratification + screening workup + dispositional routing to disease-specific engines. ME/CFS IOM 2015 criteria evaluated when other causes excluded. Phenotypes covered (≥8): sleep_disorders_osa_narcolepsy_rls (~20-30%), depression_anxiety_psychiatric (~20%), anemia_anchored (~10-15%), hypothyroid_screen, hyperthyroid_screen, dm_uncontrolled, ckd_uremic, chf_low_output, chronic_infection_hiv_hcv_tb, malignancy_paraneoplastic, me_cfs_iom_2015, fibromyalgia_overlap, postviral_post_covid_long_covid, medication_induced, deconditioning_lifestyle, adrenal_insufficiency, rheumatologic_inflammatory, b12_folate_deficiency. Bayesian linkage (LR+, LR−, pre-test priors by age/sex, IOM 2015 ME/CFS thresholds, T_treat) lives in companion depth bundle _briefs/symptom.fatigue.v1.depth.md. 5 sibling differentiation rows: symptom.anemia-workup + psych.depression + endo.dm2 + id.covid19 + geriatrics.frailty-polypharmacy (all confirmed in ALL_DOSSIERS). 10 severity_triggers: severe_depression_si, osa_high_risk, me_cfs_iom_2015, long_covid_chronic, hiv_positive, hcv_chronic, severe_thyrotoxicosis, cardiac_low_output_hf, severe_anemia, geriatric_frailty. KEY SAFETY RULES: PHQ-9 ≥20 + SI → ED for psychiatric eval + safety plan; ME/CFS uses pacing NOT graded exercise therapy (IOM 2015 / CDC PMID 26561523 verify); modafinil ONLY for narcolepsy / OSA residual sleepiness (AVOID off-label for ME/CFS / depression); CPAP for OSA confirmed by polysomnography; universal HIV + HCV screening; B12 / iron repletion when deficient. Calculators wired (0): schema-blocked — calc.stop_bang, calc.epworth, calc.iom_me_cfs_criteria, calc.fibromyalgia_acr_2016, calc.phq9, calc.gds. Ticketed in shard-3 state file. Panels wired: panel.cbc + panel.renal + panel.lft + panel.thyroid + panel.inflammation + panel.iron + panel.lipid. Schema-blocked: workup.chronic_fatigue — NOT in clinical-tools-registry; manual application in setting playbook required_assessments. Regimen_axes intentionally empty — engine is triage-only. Stepwise pharmacologic ladder lives in setting_playbooks.outpatient.drug_actions. Setting playbook: single outpatient (per chronic engine convention) — ED triage and inpatient via escalation_triggers when needed (severe depression with SI, severe thyrotoxicosis, DKA, severe anemia with instability, etc.). SCAFFOLDED status: no workup.chronic_fatigue in clinical-tools-registry; PRODUCTION audit would fail. Will promote once registry entries land.

Entry points (18)

  • symptom
    Chronic fatigue + snoring + witnessed apnea + daytime sleepiness + obesity (STOP-BANG ≥3) — OSA screen; route to polysomnography; consider narcolepsy (cataplexy, hypnagogic hallucinations), RLS, periodic limb movement disorder
    sleep_disorders_osa_narcolepsy_rls_screen
  • symptom
    Chronic fatigue + anhedonia + depressed mood + sleep disturbance + appetite change + concentration problems + PHQ-9 ≥10 — depression; route psych.depression.core.v1; comorbid anxiety / substance use common
    depression_anxiety_psychiatric_anchored
  • symptom
    Chronic fatigue + pallor + dyspnea on exertion + Hb <12 (women) / <13 (men) — anemia workup; route symptom.anemia-workup.v1; iron-deficiency most common cause
    anemia_anchored_fatigue
  • symptom
    Chronic fatigue + cold intolerance + weight gain + constipation + bradycardia + elevated TSH — hypothyroidism; levothyroxine; if severe with myxedema → ED
    hypothyroid_screen_fatigue
  • symptom
    Chronic fatigue + heat intolerance + tachycardia + tremor + weight loss + suppressed TSH — hyperthyroidism; methimazole; if severe → route endo.thyroid-storm.core.v1
    hyperthyroid_screen_fatigue
  • symptom
    Chronic fatigue + polyuria + polydipsia + glucose >200 + HbA1c >6.5% — uncontrolled DM; route endo.dm2.core.v1; fatigue from chronic hyperglycemia + osmotic diuresis
    dm_uncontrolled_fatigue
  • symptom
    Chronic fatigue + eGFR <30 + uremic features (anorexia, pruritus, restless legs, sleep disturbance) — uremic fatigue; route neph.ckd.core.v1; renal anemia, secondary hyperPTH, sleep disorders contribute
    ckd_uremic_fatigue
  • symptom
    Chronic fatigue + dyspnea + orthopnea + reduced EF + LE edema — low-output HF / HFrEF; route cardio.hfref.core.v1; GDMT optimization; fatigue is class III-IV symptom
    chf_low_output_fatigue
  • symptom
    Chronic fatigue + risk factors (sexual, IDU, transfusion, endemic exposure) + lymphadenopathy + B-symptoms — HIV / HCV / TB / EBV reactivation; route id.hiv-initial.chronic.v1 or id.hcv-initial.chronic.v1
    chronic_infection_hiv_hcv_tb_fatigue
  • symptom
    Chronic fatigue + WL + B-symptoms + lymphadenopathy + new mass / pain — malignancy / paraneoplastic; CT C/A/P + age-appropriate cancer screen
    malignancy_paraneoplastic_fatigue
  • symptom
    Chronic fatigue ≥6 mo + post-exertional malaise + unrefreshing sleep + cognitive impairment OR orthostatic intolerance + substantial functional decline — ME/CFS per IOM 2015 (PMID 25695122 — verify); diagnosis of exclusion + symptom criteria
    me_cfs_iom_2015_criteria
  • symptom
    Chronic fatigue + widespread pain >3 mo + multiple tender points + cognitive symptoms + sleep disturbance — fibromyalgia (ACR 2016 criteria); duloxetine / pregabalin / SNRI; aerobic exercise; CBT
    fibromyalgia_overlap_fatigue
  • symptom
    Chronic fatigue + cognitive / autonomic / cardiopulmonary symptoms ≥3 mo after acute COVID — post-COVID / long COVID; route id.covid19.core.v1; multidisciplinary care
    postviral_post_covid_long_covid
  • symptom
    Chronic fatigue + medication review reveals β-blocker / antihistamine / benzodiazepine / opioid / antidepressant / statin / antipsychotic / antiepileptic — drug-induced; deprescribe or substitute when feasible
    medication_induced_fatigue
  • symptom
    Chronic fatigue + sedentary lifestyle + poor sleep hygiene + caffeine excess + alcohol use + low physical activity — deconditioning / lifestyle; graded exercise + sleep hygiene + nutritional counseling
    deconditioning_lifestyle_factors
  • symptom
    Chronic fatigue + orthostasis + hyperpigmentation + hyponatremia + hyperkalemia + nausea + WL — adrenal insufficiency (Addison); morning cortisol + ACTH; replacement therapy
    adrenal_insufficiency_fatigue
  • symptom
    Chronic fatigue + arthralgia + morning stiffness + serositis + rash + Raynaud + elevated CRP/ESR — rheumatologic (RA, SLE, vasculitis, PMR, Sjögren); ANA / RF / anti-CCP / ANCA
    rheumatologic_inflammatory_fatigue
  • symptom
    Chronic fatigue + cognitive symptoms + paresthesias + macrocytic anemia + low B12 (<200 pg/mL) — B12 deficiency (NEJM 2013 PMID 22106456); folate; check intrinsic factor antibodies (pernicious anemia)
    b12_folate_deficiency_fatigue

Required inputs (39)

  • agerequired
    demographic • used at CONTEXT
    Age shifts priors: young adult → depression / chronic infection / ME/CFS / postviral; middle-age → depression / hypothyroid / DM / chronic disease; elderly → hypothyroid / cardiac / renal / depression / geriatric frailty / medication-induced (Mark 2011 PMID 19490842 — verify)
  • sexrequired
    demographic • used at CONTEXT
    Sex shifts priors: female > male for hypothyroid, anemia, fibromyalgia, ME/CFS, depression, autoimmune; male > female for OSA (overlap with obesity), HCV / IDU history
  • duration_and_pattern_of_fatiguerequired
    symptom • used at FRAME
    Chronic fatigue defined as ≥6 mo (IOM 2015 — verify); pattern: post-exertional malaise (ME/CFS), morning > evening (hypothyroid), evening > morning (depression), exercise-induced (cardiac low-output)
  • functional_impact_substantial_declinerequired
    symptom • used at FRAME
    Substantial functional decline (≥50% from baseline) part of IOM 2015 ME/CFS criteria; differentiates clinical fatigue from "tired" complaint; quality-of-life measures
  • post_exertional_malaiserequired
    symptom • used at ENTRY
    PEM (worsening of symptoms 24-48 h after physical / cognitive / emotional exertion) — hallmark of ME/CFS per IOM 2015 (PMID 25695122); not typical in depression / deconditioning
  • unrefreshing_sleep_or_sleep_disturbancerequired
    symptom • used at ENTRY
    Unrefreshing sleep (sleep without restoration) — IOM 2015 ME/CFS criterion; also seen in OSA, depression, RLS, fibromyalgia, chronic pain
  • cognitive_brain_fog_concentrationrequired
    symptom • used at ENTRY
    Cognitive impairment (brain fog, decreased concentration, memory) — IOM 2015 ME/CFS; also in depression, hypothyroid, B12 deficiency, OSA, long COVID
  • orthostatic_intolerance
    symptom • used at ENTRY
    Orthostatic intolerance (POTS, neurally mediated hypotension) — alternative IOM 2015 ME/CFS criterion to cognitive impairment; also adrenal insufficiency, autonomic neuropathy
  • mood_anhedonia_psych_featuresrequired
    symptom • used at ENTRY
    PHQ-9 ≥10 + anhedonia + sleep / energy disturbance → depression (most common cause of chronic fatigue in primary care; route psych.depression.core.v1)
  • sleep_quality_snoring_witnessed_apnea_stop_bangrequired
    symptom • used at CONTEXT
    STOP-BANG screen (snoring, tired, observed apnea, BP, BMI >35, age >50, neck >40 cm, male sex) → ≥3 OSA likely; polysomnography referral
  • weight_change_appetite_temp_intolerancerequired
    symptom • used at CONTEXT
    WL → malignancy / hyperthyroid / DM / depression; weight gain → hypothyroid / depression with carb craving; cold intolerance → hypothyroid; heat intolerance → hyperthyroid
  • pain_widespread_arthralgia
    symptom • used at ENTRY
    Widespread pain → fibromyalgia (ACR 2016); arthralgia + morning stiffness → RA / SLE / vasculitis; muscle pain → statin / hypothyroid / rheumatologic
  • medication_review_beta_blocker_antihistamine_bzd_opioid_antidepressantrequired
    history • used at CONTEXT
    β-blocker, antihistamine (especially first-gen), BZD, opioid, antidepressant (mirtazapine, TCA), statin (rare myalgia), antipsychotic, antiepileptic — drug-induced fatigue; deprescribe or substitute
  • chronic_disease_history_dm_ckd_hf_copd_cancerrequired
    history • used at CONTEXT
    DM (chronic hyperglycemia), CKD (uremia, anemia, secondary hyperPTH), HF (low cardiac output), COPD (hypoxia), cancer (paraneoplastic, treatment-related); each routes to disease-specific engine
  • infection_history_hiv_hcv_tb_ebv_lymerequired
    history • used at CONTEXT
    HIV (universal screen); HCV (IDU, transfusion); TB (endemic, contact); EBV reactivation; Lyme (endemic, tick exposure); each routes to disease-specific engine
  • recent_acute_illness_postviral_post_covidrequired
    history • used at CONTEXT
    Post-viral fatigue / post-COVID / long COVID (≥3 mo after acute COVID) — common cause of chronic fatigue post-2020; route id.covid19.core.v1; multidisciplinary care
  • lifestyle_caffeine_alcohol_exercise_sleep_hygiene
    history • used at CONTEXT
    Lifestyle factors: caffeine excess, alcohol use, sedentary lifestyle, poor sleep hygiene, screen time, shift work — modifiable; deconditioning common
  • rheumatologic_family_autoimmune_history
    history • used at CONTEXT
    Family hx autoimmune (RA, SLE, MS, thyroid); personal hx Raynaud, sicca symptoms; rheumatologic workup if elevated CRP/ESR + features
  • red_flags_neuro_cardiac_severe_systemicrequired
    symptom • used at RED_FLAGS
    Red flags: new focal neuro deficit, severe chest pain, syncope, severe weight loss >10%, hemoptysis, painless lymphadenopathy >2 cm, severe SOB → ED workup
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Anemia (most common: iron-deficiency → symptom.anemia-workup; macrocytic → B12/folate; pancytopenia → marrow / lymphoma); leukocytosis (chronic infection); lymphocytosis (lymphoma, EBV)
  • bmp_glucose_electrolytesrequired
    lab • used at INITIAL_WORKUP
    Glucose / HbA1c (DM); BUN/Cr (CKD); Na (SIADH, Addison); K (Addison); Ca (hyperPTH); fasting glucose if non-diabetic
  • lft_albuminrequired
    lab • used at INITIAL_WORKUP
    LFT (hepatic disease, alcohol, drug-induced, HCV); albumin (chronic disease, nutrition); hepatitis screen if elevated
  • tsh_t4_freerequired
    lab • used at INITIAL_WORKUP
    TSH (elevated → hypothyroid; suppressed → hyperthyroid); first-line endocrine workup; reflex T4/T3 if abnormal
  • hba1c_fasting_glucoserequired
    lab • used at INITIAL_WORKUP
    HbA1c ≥6.5% / fasting glucose ≥126 → DM screen; route endo.dm2.core.v1; pre-diabetic counseling if 5.7-6.4%
  • b12_folate_iron_studiesrequired
    lab • used at INITIAL_WORKUP
    B12 <200 → deficiency (route symptom.anemia-workup if MCV high); folate; iron studies (ferritin <30 → iron-deficiency; transferrin saturation)
  • crp_esr_inflammationrequired
    lab • used at INITIAL_WORKUP
    CRP / ESR — inflammatory screen; elevated → rheumatologic / chronic infection / malignancy; ESR >100 nonspecific concerning marker
  • hiv_universal_screenrequired
    lab • used at INITIAL_WORKUP
    Universal HIV screen (CDC, USPSTF); HCV screen (USPSTF universal adults); syphilis if risk factors
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    UA — proteinuria (CKD); glucose (DM); hematuria (renal disease)
  • phq9_geriatric_depression_scalerequired
    lab • used at CONTEXT
    PHQ-9 ≥10 → depression; GDS for ≥65; PHQ-9 ≥20 → severe depression with suicide risk screen (PHQ-9 item 9)
  • stop_bang_questionnaire
    lab • used at CONTEXT
    STOP-BANG ≥3 → OSA likely; polysomnography referral; ≥5 → high-risk OSA
  • cortisol_acth_morning
    lab • used at BRANCHING_WORKUP
    Adrenal insufficiency screen — morning cortisol <5 µg/dL + ACTH > 100 → Addison; orthostasis + hyperpigmentation + hyponatremia clinical features
  • ana_rf_anti_ccp_anca_if_rheum_features
    lab • used at BRANCHING_WORKUP
    Rheumatologic workup if arthralgia + morning stiffness + elevated CRP/ESR + features (Raynaud, sicca, rash); route to rheumatology if positive
  • hcv_screen_universalrequired
    lab • used at INITIAL_WORKUP
    HCV universal adult screening (USPSTF); IDU / transfusion history; chronic fatigue is common HCV presentation; route id.hcv-initial.chronic.v1
  • tb_igra_if_endemic
    lab • used at BRANCHING_WORKUP
    TB IGRA if endemic exposure / chronic cough / WL / B-symptoms; latent vs active workup
  • lyme_serology_if_endemic_tick_exposure
    lab • used at BRANCHING_WORKUP
    Lyme serology if endemic exposure + tick history + erythema migrans / arthralgia / cognitive symptoms; chronic Lyme is controversial
  • epworth_sleepiness_scale
    lab • used at CONTEXT
    Epworth >10 → excessive daytime sleepiness; combined with STOP-BANG for OSA / narcolepsy screening
  • cxr_if_pulmonary_features
    imaging • used at INITIAL_WORKUP
    CXR — interstitial disease, TB, malignancy, HF (cardiomegaly, congestion); first-line lung screen
  • echocardiogram_if_cardiac_features
    imaging • used at BRANCHING_WORKUP
    TTE — reduced EF (cardiac low-output); valvular disease; diastolic dysfunction; pericardial effusion; route cardio.hfref.core.v1 if EF <40%
  • polysomnography_if_stop_bang_high
    imaging • used at BRANCHING_WORKUP
    Polysomnography — confirm OSA (AHI ≥5 mild, ≥15 moderate, ≥30 severe); narcolepsy (MSLT); RLS / PLMD evaluation

12-phase flow (12)

  1. 1FRAME
    Document chronic fatigue ≥6 mo (IOM 2015 criteria for ME/CFS); substantial functional decline (≥50% from baseline); rule out acute / subacute fatigue (<6 mo); calibrate baseline activity / quality-of-life
    inputs: duration_and_pattern_of_fatigue, functional_impact_substantial_decline
    advance: Chronic ≥6 mo + functional decline documented
  2. 2ENTRY
    Phenotype-defining features: PEM (post-exertional malaise — ME/CFS signature), unrefreshing sleep, cognitive impairment, orthostatic intolerance, mood, pain, sleep quality — anchor entry phenotype
    inputs: post_exertional_malaise, unrefreshing_sleep_or_sleep_disturbance, cognitive_brain_fog_concentration, orthostatic_intolerance, mood_anhedonia_psych_features, pain_widespread_arthralgia
    advance: Phenotype tentative
  3. 3CONTEXT
    Age + sex + medication review (β-blocker, antihistamine, BZD, opioid, antidepressant, statin) + chronic disease (DM, CKD, HF, COPD, cancer) + infection history (HIV, HCV, TB, EBV, Lyme) + post-COVID / postviral + lifestyle (caffeine, alcohol, sleep hygiene, exercise) + rheumatologic family + sleep quality (STOP-BANG, Epworth) + weight / appetite / temperature intolerance
    inputs: age, sex, medication_review_beta_blocker_antihistamine_bzd_opioid_antidepressant, chronic_disease_history_dm_ckd_hf_copd_cancer, infection_history_hiv_hcv_tb_ebv_lyme, recent_acute_illness_postviral_post_covid, lifestyle_caffeine_alcohol_exercise_sleep_hygiene, rheumatologic_family_autoimmune_history, sleep_quality_snoring_witnessed_apnea_stop_bang, weight_change_appetite_temp_intolerance, phq9_geriatric_depression_scale
    advance: Context comprehensive + medication audit complete
  4. 4RED_FLAGS
    Red flags requiring ED / urgent workup: new focal neuro deficit, severe chest pain, syncope, severe weight loss >10%, hemoptysis, painless lymphadenopathy >2 cm, severe SOB; severe depression with suicidal ideation; severe thyrotoxicosis; new DKA; severe anemia with hemodynamic instability
    inputs: red_flags_neuro_cardiac_severe_systemic
    advance: Red flags ruled out OR ED routed
  5. 5INITIAL_WORKUP
    CBC + diff (anemia, leukocytosis, lymphocytosis); BMP + glucose (DM, CKD, electrolytes); LFT + albumin (hepatic, alcohol, nutrition); TSH + T4 (thyroid); HbA1c (DM); B12 + folate + iron studies (deficiencies); CRP + ESR (inflammation); HIV + HCV (universal screens); UA; PHQ-9 / GDS (depression); STOP-BANG + Epworth (sleep)
    inputs: cbc_with_diff, bmp_glucose_electrolytes, lft_albumin, tsh_t4_free, hba1c_fasting_glucose, b12_folate_iron_studies, crp_esr_inflammation, hiv_universal_screen, hcv_screen_universal, urinalysis
    actions: panel.cbc, panel.renal, panel.lft, panel.thyroid, panel.inflammation, panel.iron
    advance: Tier 1 returned + cause stratification preliminary
  6. 6BRANCHING_WORKUP
    Anemia found → route symptom.anemia-workup.v1. Hypothyroid → levothyroxine; hyperthyroid → methimazole (severe → endo.thyroid-storm). DM → route endo.dm2.core.v1. CKD → route neph.ckd.core.v1. HF features → echocardiogram → route cardio.hfref.core.v1 if EF<40%. HIV/HCV → route ID engines. Sleep disorder → polysomnography. Depression → route psych.depression.core.v1. Rheumatologic features → ANA / RF / anti-CCP / ANCA / rheumatology referral. Adrenal insufficiency screen if orthostatic + hyperpigmentation + hyponatremia. TB / Lyme if endemic. Post-COVID → multidisciplinary clinic / route id.covid19.core.v1. ME/CFS IOM 2015 criteria evaluated as diagnosis of exclusion + symptom criteria.
    inputs: cortisol_acth_morning, ana_rf_anti_ccp_anca_if_rheum_features, tb_igra_if_endemic, lyme_serology_if_endemic_tick_exposure, epworth_sleepiness_scale, cxr_if_pulmonary_features, echocardiogram_if_cardiac_features, polysomnography_if_stop_bang_high
    advance: Targeted workup complete or routed to specific engine
  7. 7DIFFERENTIAL
    Sleep disorders (~20-30% — OSA, narcolepsy, RLS, PLMD); Depression / psychiatric (~20% — most common in primary care); Anemia (~10-15%); Endocrine (~10% — hypothyroid most common); DM uncontrolled; CKD uremic; Cardiac low-output (HFrEF); Chronic infection (~5% — HIV, HCV, TB, EBV); Malignancy / paraneoplastic; ME/CFS (~1-2% — IOM 2015 criteria); Fibromyalgia overlap; Post-COVID / long COVID (significant post-2020); Medication-induced (~10%); Deconditioning / lifestyle; B12 / folate deficiency; Adrenal insufficiency; Rheumatologic; Undiagnosed (~20% — many self-resolve or evolve)
    advance: Differential ranked
  8. 8RISK_STRATIFICATION
    Severity by functional impact (housebound, bedbound, work-impaired); IOM 2015 ME/CFS criteria (all required for dx); fibromyalgia ACR 2016 (widespread pain index + symptom severity); depression by PHQ-9 (10-14 moderate, 15-19 moderately severe, ≥20 severe); sleep disorder severity (AHI grading); cardiac functional class (NYHA); CKD stage; cancer screening risk
    advance: Risk-stratified disposition documented
  9. 9TREATMENT
    Cause-directed: depression → SSRI / SNRI + psychotherapy (CBT); anemia → route + supplementation; hypothyroid → levothyroxine; hyperthyroid → methimazole / RAI / surgery; DM → glycemic control + lifestyle; CKD → dietary + dialysis planning; HF → GDMT (β-blocker, ACE-I/ARNI, MRA, SGLT2i); OSA → CPAP / BiPAP / oral appliance / weight loss / positional therapy; ME/CFS → pacing + symptom mgmt (NOT graded exercise therapy per IOM 2015 / CDC PMID 26561523 — verify); fibromyalgia → duloxetine / pregabalin / SNRI + aerobic exercise + CBT; long COVID → multidisciplinary + symptom mgmt + pacing; medication deprescribing; sleep hygiene + lifestyle counseling; adrenal insufficiency → hydrocortisone replacement; rheumatologic → DMARD / biologic per specialist
    inputs: medication_review_beta_blocker_antihistamine_bzd_opioid_antidepressant
    advance: Treatment initiated or routed to specific engine
  10. 10DISPOSITION
    Home (most): outpatient stepwise workup + lifestyle counseling + return precautions; subspecialty referral: GI / endocrine / psych / sleep medicine / cardiology / nephrology / pulmonary / rheumatology / ID / oncology; multidisciplinary clinic for ME/CFS / fibromyalgia / long COVID; ED if severe red flags (suicidal ideation, severe thyrotoxicosis, DKA, severe anemia with hemodynamic instability); inpatient rare (psych admission, severe medical decompensation)
    advance: Disposition assigned
  11. 11MONITORING
    Symptom diary (energy, sleep, mood, pain, cognition); PHQ-9 trend if depression-treated (4-6 wk after SSRI); TSH 6 wk after thyroid therapy; HbA1c 3 mo after DM tx; CBC if anemia treated; polysomnography result + CPAP compliance / titration; ME/CFS pacing diary; fibromyalgia response to duloxetine / aerobic exercise; long COVID multidisciplinary follow-up; medication deprescribing review
    advance: Monitoring plan in place
  12. 12FOLLOWUP
    Lifestyle reinforcement (sleep hygiene, graded activity, nutritional counseling, caffeine reduction, alcohol moderation); psychiatry follow-up (CBT, SSRI/SNRI); chronic disease optimization; cancer screening intervals; sleep clinic for CPAP compliance; ME/CFS pacing (NOT GET); fibromyalgia multidisciplinary; long COVID rehab; rheumatology follow-up; geriatric long-term planning
    advance: Long-term plan documented + follow-up scheduled