Patient handout

Chronic fatigue (outpatient symptom triage)

PRODUCTION

1. Your condition

This handout is for chronic fatigue (outpatient symptom triage). Your care team identified this based on: 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.

Other reasons your team may use this plan: 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; chronic fatigue + pallor + dyspnea on exertion + hb <12 (women) / <13 (men) — anemia workup; route symptom.anemia-workup.v1; iron-deficiency most common cause; chronic fatigue + cold intolerance + weight gain + constipation + bradycardia + elevated tsh — hypothyroidism; levothyroxine; if severe with myxedema → ed.

3. When to call your provider

Contact your care team if any of the following happen:

New focal neuro deficit / sudden severe headache / vision change → ED for STAT imaging
Severe chest pain / syncope → ED for cardiac workup
Severe weight loss >10% in 6 mo with red flags → CT C/A/P + cancer screen STAT
Severe depression + active suicidal ideation → ED for psychiatric eval + safety plan
Severe thyrotoxicosis (T >38.5 + AF + AMS) → route endo.thyroid-storm.core.v1 + ED
New DKA in T1DM (glucose >300 + ketones + acidosis) → route endo.dka.core.v1
Severe anemia (Hb <7) + hemodynamic instability → ED for transfusion
Acute decompensated HF in HFrEF cachexia → route cardio.acute-hf.core.v1 + ED
New malignancy on imaging or labs → oncology referral STAT
Hemoptysis / painless lymphadenopathy >2 cm / palpable mass → urgent oncology workup
Active TB → public health reporting + ID + RIPE + airborne isolation

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Chronic fatigue + PHQ-9 ≥20 + active suicidal ideation with plan — emergent psychiatric admission; route psych.depression.core.v1; safety plan + 1:1 observation; SSRI initiation(life-threatening)
STOP-BANG ≥5 OR witnessed apnea + severe daytime sleepiness (Epworth >15) — OSA likely severe; polysomnography STAT; CPAP titration; weight loss; positional therapy; cardiovascular risk modification
Chronic fatigue + HIV positive on universal screen + risk factors — route id.hiv-initial.chronic.v1 + ART; chronic infection is ~5% of chronic fatigue; opportunistic infection screen by CD4
Chronic fatigue + heat intolerance + tachycardia + AF + high-output features + TSH <0.1 + T4/T3 elevated + impending storm features (T >38.5, AMS) — severe thyrotoxicosis; route endo.thyroid-storm.core.v1(life-threatening)
Chronic fatigue + dyspnea + orthopnea + LE edema + reduced EF on echo (<40%) — HFrEF with low-output fatigue; route cardio.hfref.core.v1 + the four foundational heart-failure medications optimization
Chronic fatigue + Hb <8 + symptomatic (dyspnea, syncope, angina) — severe anemia; route symptom.anemia-workup.v1 + transfusion + cause workup; iron-deficiency most common

5. Follow-up

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

6. Sources

Guideline: IOM 2015 ME/CFS report (PMID 25695122 — verify) + CDC ME/CFS guidance (PMID 26561523 — verify) + post-COVID Long COVID (PMID 32673060 / 34000130 — verify) + 2017 NEJM fatigue (PMID 30077542 — verify) + 2011 Mark fatigue review (PMID 19490842 — verify) + NEJM B12 2013 (PMID 22106456) + USPSTF universal HIV/HCV screening + ACR 2016 fibromyalgia criteria