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symptom.fatigue.v1PRODUCTION
symptom.fatigue.v1

Chronic fatigue (outpatient symptom triage)

symptomchronicundifferentiatedadultgeriatric
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Detailed

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

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Chronic ≥6 mo + functional decline documented

Patient inputs (39)

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)

Sex shifts priors: female > male for hypothyroid, anemia, fibromyalgia, ME/CFS, depression, autoimmune; male > female for OSA (overlap with obesity), HCV / IDU history

STOP-BANG screen (snoring, tired, observed apnea, BP, BMI >35, age >50, neck >40 cm, male sex) → ≥3 OSA likely; polysomnography referral

WL → malignancy / hyperthyroid / DM / depression; weight gain → hypothyroid / depression with carb craving; cold intolerance → hypothyroid; heat intolerance → hyperthyroid

β-blocker, antihistamine (especially first-gen), BZD, opioid, antidepressant (mirtazapine, TCA), statin (rare myalgia), antipsychotic, antiepileptic — drug-induced fatigue; deprescribe or substitute

DM (chronic hyperglycemia), CKD (uremia, anemia, secondary hyperPTH), HF (low cardiac output), COPD (hypoxia), cancer (paraneoplastic, treatment-related); each routes to disease-specific engine

HIV (universal screen); HCV (IDU, transfusion); TB (endemic, contact); EBV reactivation; Lyme (endemic, tick exposure); each routes to disease-specific engine

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

PHQ-9 ≥10 → depression; GDS for ≥65; PHQ-9 ≥20 → severe depression with suicide risk screen (PHQ-9 item 9)

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 (sleep without restoration) — IOM 2015 ME/CFS criterion; also seen in OSA, depression, RLS, fibromyalgia, chronic pain

Cognitive impairment (brain fog, decreased concentration, memory) — IOM 2015 ME/CFS; also in depression, hypothyroid, B12 deficiency, OSA, long COVID

PHQ-9 ≥10 + anhedonia + sleep / energy disturbance → depression (most common cause of chronic fatigue in primary care; route psych.depression.core.v1)

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)

Substantial functional decline (≥50% from baseline) part of IOM 2015 ME/CFS criteria; differentiates clinical fatigue from "tired" complaint; quality-of-life measures

Anemia (most common: iron-deficiency → symptom.anemia-workup; macrocytic → B12/folate; pancytopenia → marrow / lymphoma); leukocytosis (chronic infection); lymphocytosis (lymphoma, EBV)

Glucose / HbA1c (DM); BUN/Cr (CKD); Na (SIADH, Addison); K (Addison); Ca (hyperPTH); fasting glucose if non-diabetic

LFT (hepatic disease, alcohol, drug-induced, HCV); albumin (chronic disease, nutrition); hepatitis screen if elevated

TSH (elevated → hypothyroid; suppressed → hyperthyroid); first-line endocrine workup; reflex T4/T3 if abnormal

HbA1c ≥6.5% / fasting glucose ≥126 → DM screen; route endo.dm2.core.v1; pre-diabetic counseling if 5.7-6.4%

B12 <200 → deficiency (route symptom.anemia-workup if MCV high); folate; iron studies (ferritin <30 → iron-deficiency; transferrin saturation)

CRP / ESR — inflammatory screen; elevated → rheumatologic / chronic infection / malignancy; ESR >100 nonspecific concerning marker

Universal HIV screen (CDC, USPSTF); HCV screen (USPSTF universal adults); syphilis if risk factors

UA — proteinuria (CKD); glucose (DM); hematuria (renal disease)

HCV universal adult screening (USPSTF); IDU / transfusion history; chronic fatigue is common HCV presentation; route id.hcv-initial.chronic.v1

Red flags: new focal neuro deficit, severe chest pain, syncope, severe weight loss >10%, hemoptysis, painless lymphadenopathy >2 cm, severe SOB → ED workup

Adrenal insufficiency screen — morning cortisol <5 µg/dL + ACTH > 100 → Addison; orthostasis + hyperpigmentation + hyponatremia clinical features

Rheumatologic workup if arthralgia + morning stiffness + elevated CRP/ESR + features (Raynaud, sicca, rash); route to rheumatology if positive

TB IGRA if endemic exposure / chronic cough / WL / B-symptoms; latent vs active workup

Lyme serology if endemic exposure + tick history + erythema migrans / arthralgia / cognitive symptoms; chronic Lyme is controversial

TTE — reduced EF (cardiac low-output); valvular disease; diastolic dysfunction; pericardial effusion; route cardio.hfref.core.v1 if EF <40%

Polysomnography — confirm OSA (AHI ≥5 mild, ≥15 moderate, ≥30 severe); narcolepsy (MSLT); RLS / PLMD evaluation

Lifestyle factors: caffeine excess, alcohol use, sedentary lifestyle, poor sleep hygiene, screen time, shift work — modifiable; deconditioning common

Family hx autoimmune (RA, SLE, MS, thyroid); personal hx Raynaud, sicca symptoms; rheumatologic workup if elevated CRP/ESR + features

STOP-BANG ≥3 → OSA likely; polysomnography referral; ≥5 → high-risk OSA

Epworth >10 → excessive daytime sleepiness; combined with STOP-BANG for OSA / narcolepsy screening

Orthostatic intolerance (POTS, neurally mediated hypotension) — alternative IOM 2015 ME/CFS criterion to cognitive impairment; also adrenal insufficiency, autonomic neuropathy

Widespread pain → fibromyalgia (ACR 2016); arthralgia + morning stiffness → RA / SLE / vasculitis; muscle pain → statin / hypothyroid / rheumatologic

CXR — interstitial disease, TB, malignancy, HF (cardiomegaly, congestion); first-line lung screen

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningsevere_depression_with_suicidal_ideation
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_thyrotoxicosis_with_fatigue
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereosa_high_risk_stop_bang_severe
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_positive_chronic_fatigue
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiac_low_output_hf_fatigue
    Chronic fatigue + dyspnea + orthopnea + LE edema + reduced EF on echo (<40%) — HFrEF with low-output fatigue; route cardio.hfref.core.v1 + GDMT optimization
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_anemia_with_fatigue
    Chronic fatigue + Hb <8 + symptomatic (dyspnea, syncope, angina) — severe anemia; route symptom.anemia-workup.v1 + transfusion + cause workup; iron-deficiency most common
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateme_cfs_iom_2015_criteria_met
    Chronic fatigue ≥6 mo + substantial functional decline + PEM + unrefreshing sleep + (cognitive impairment OR orthostatic intolerance) — ME/CFS per IOM 2015 (PMID 25695122 — verify); diagnosis of exclusion + symptom criteria; pacing + symptom-directed pharmacotherapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelong_covid_post_covid_chronic
    Chronic fatigue + cognitive / autonomic / cardiopulmonary symptoms ≥3 mo after acute COVID (PMID 32673060 / 34000130 — verify) — long COVID; route id.covid19.core.v1; multidisciplinary care
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehcv_chronic_fatigue
    Chronic fatigue + HCV positive on universal screen (USPSTF) + IDU / transfusion / endemic — route id.hcv-initial.chronic.v1 + DAA therapy; chronic fatigue is common HCV presentation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_frailty_fatigue
    Elderly (≥65) + chronic fatigue + functional decline + decreased social engagement + polypharmacy — geriatric frailty; route geriatrics.frailty-polypharmacy.core.v1; CGA + deprescribing
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

outpatient playbook — drug actions (13)

  1. 1. lifestyle counseling (sleep hygiene + graded activity + caffeine reduction + alcohol moderation + nutritional counseling)
    Sleep 7-9 h regular schedule; reduce caffeine after noon; avoid alcohol within 3 h of sleep; mediterranean diet; daily light exercise (NOT graded exercise therapy for ME/CFS) • behavioral • daily
    trigger: All chronic fatigue
    First-line; addresses modifiable lifestyle factors; foundation for all other interventions; NOTE: ME/CFS uses pacing, NOT graded exercise therapy per IOM 2015 / CDC PMID 26561523
  2. 2. sertraline OR escitalopram (SSRI for depression)
    Sertraline 50 mg PO daily, titrate to 100-200 mg; escitalopram 10 mg PO daily, titrate to 20 mg • PO • daily
    trigger: Depression (PHQ-9 ≥10) + chronic fatigue; route psych.depression.core.v1 for full management
    First-line SSRI for depression with fatigue; sertraline well-tolerated; escitalopram has fewer drug-drug interactions; 4-6 wk for response; PHQ-9 trend monitoring
  3. 3. duloxetine (SNRI for fibromyalgia + depression overlap)
    30 mg PO daily x 1 wk, then 60 mg PO daily; max 120 mg • PO • daily
    trigger: Fibromyalgia + chronic fatigue + depression overlap
    FDA approved for fibromyalgia + depression; addresses pain + fatigue + mood; avoid in uncontrolled glaucoma
  4. 4. pregabalin (for fibromyalgia)
    75 mg PO BID, titrate to 150-225 mg BID • PO • BID
    trigger: Fibromyalgia + sleep disturbance
    FDA approved for fibromyalgia; addresses pain + sleep; somnolence + weight gain common AE; renal-dose adjust
  5. 5. levothyroxine (for hypothyroidism)
    1.6 µg/kg/d PO daily; start 25-50 µg in elderly + cardiac • PO • daily on empty stomach
    trigger: Hypothyroidism (TSH >5 + symptoms)
    First-line; TSH recheck at 6 wk; cautious in elderly + cardiac (start low); take 30-60 min before food / other meds
  6. 6. methimazole (for hyperthyroidism)
    5-30 mg PO daily • PO • daily
    trigger: Hyperthyroidism (TSH <0.1 + elevated T4/T3); severe → route endo.thyroid-storm.core.v1
    First-line antithyroid; PTU in first-trimester pregnancy; RAI / surgery for definitive; β-blocker for symptomatic control
  7. 7. CPAP for OSA (route sleep medicine)
    CPAP titrated by polysomnography; auto-PAP alternative • CPAP device • nightly with sleep
    trigger: OSA confirmed by polysomnography (AHI ≥5)
    First-line for OSA; weight loss adjunct; oral appliance for mild-moderate; positional therapy if positional OSA; addresses fatigue + cardiovascular risk
  8. 8. iron supplementation (for iron-deficiency anemia)
    Ferrous sulfate 325 mg PO daily or QOD; IV iron if PO intolerant • PO / IV • daily / QOD
    trigger: Iron-deficiency anemia (ferritin <30; route symptom.anemia-workup.v1 for full workup)
    PO first-line; QOD dosing may improve absorption (Camaschella NEJM 2015 PMID 32513860); IV for malabsorption / intolerance / chronic loss
  9. 9. B12 supplementation (for B12 deficiency)
    Cyanocobalamin 1000 µg PO daily or IM monthly • PO / IM • daily / monthly
    trigger: B12 deficiency (<200 pg/mL) + neuro-psych symptoms (NEJM 2013 PMID 22106456)
    PO equivalent to IM for absorption; IM if neurologic symptoms / pernicious anemia / severe deficiency; check intrinsic factor antibodies
  10. 10. pacing for ME/CFS (NOT graded exercise therapy)
    Patient-determined activity within energy envelope; avoid PEM; planned rest breaks • behavioral • ongoing
    trigger: ME/CFS confirmed per IOM 2015 criteria (PMID 25695122)
    IOM 2015 / CDC consensus — PACE trial (graded exercise therapy) NOT supported in ME/CFS; pacing within energy envelope; symptom-directed pharmacotherapy (LDN, fludrocortisone for OI); multidisciplinary care
  11. 11. multidisciplinary care for long COVID
    Per id.covid19.core.v1 • multimodal • ongoing
    trigger: Post-COVID fatigue ≥3 mo (PMID 32673060 / 34000130 — verify)
    Multidisciplinary approach (rehab, psych, sleep, cardiology, pulm); pacing if PEM; symptom-directed; route id.covid19.core.v1 for full management
  12. 12. deprescribing offending medications
    N/A — taper or substitute • N/A • one-time + monitor
    trigger: Medication-induced fatigue (β-blocker, antihistamine, BZD, opioid, antidepressant, statin)
    Substitute with appetite-neutral / activating alternative; carvedilol may have less fatigue than metoprolol; loratadine / cetirizine over diphenhydramine; SSRI / SNRI selection for activating profile
  13. 13. modafinil (for narcolepsy or refractory daytime sleepiness)
    100-400 mg PO daily • PO • AM
    trigger: Narcolepsy or refractory excessive daytime sleepiness; AVOID in chronic fatigue without sleep disorder
    FDA approved for narcolepsy + OSA-related residual sleepiness on CPAP; AVOID off-label use for ME/CFS / depression; CYP3A4 inducer

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic fatigue (outpatient symptom triage)** (symptom.fatigue.v1).
Phenotype framing: 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)
Scope: 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

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (outpatient) — Pattern-anchored chronic fatigue triage (≥6 mo): sleep disorders (~20-30%), depression / psychiatric (~20%), anemia, endocrine (hypothyroid, DM, adrenal), CKD uremic, cardiac low-output, chronic infection (HIV, HCV, TB), malignancy / paraneoplastic, ME/CFS (IOM 2015), fibromyalgia, post-COVID / long COVID, medication-induced, deconditioning, B12 deficiency. Tier 1 → Tier 2 workup; route to disease-specific engine; address cause + symptom-directed (pacing for ME/CFS; CPAP for OSA; SSRI for depression; CBT for fibromyalgia)
1. lifestyle counseling (sleep hygiene + graded activity + caffeine reduction + alcohol moderation + nutritional counseling) Sleep 7-9 h regular schedule; reduce caffeine after noon; avoid alcohol within 3 h of sleep; mediterranean diet; daily light exercise (NOT graded exercise therapy for ME/CFS) behavioral daily — All chronic fatigue (First-line; addresses modifiable lifestyle factors; foundation for all other interventions; NOTE: ME/CFS uses pacing, NOT graded exercise therapy per IOM 2015 / CDC PMID 26561523)
2. sertraline OR escitalopram (SSRI for depression) Sertraline 50 mg PO daily, titrate to 100-200 mg; escitalopram 10 mg PO daily, titrate to 20 mg PO daily — Depression (PHQ-9 ≥10) + chronic fatigue; route psych.depression.core.v1 for full management (First-line SSRI for depression with fatigue; sertraline well-tolerated; escitalopram has fewer drug-drug interactions; 4-6 wk for response; PHQ-9 trend monitoring)
3. duloxetine (SNRI for fibromyalgia + depression overlap) 30 mg PO daily x 1 wk, then 60 mg PO daily; max 120 mg PO daily — Fibromyalgia + chronic fatigue + depression overlap (FDA approved for fibromyalgia + depression; addresses pain + fatigue + mood; avoid in uncontrolled glaucoma)
4. pregabalin (for fibromyalgia) 75 mg PO BID, titrate to 150-225 mg BID PO BID — Fibromyalgia + sleep disturbance (FDA approved for fibromyalgia; addresses pain + sleep; somnolence + weight gain common AE; renal-dose adjust)
5. levothyroxine (for hypothyroidism) 1.6 µg/kg/d PO daily; start 25-50 µg in elderly + cardiac PO daily on empty stomach — Hypothyroidism (TSH >5 + symptoms) (First-line; TSH recheck at 6 wk; cautious in elderly + cardiac (start low); take 30-60 min before food / other meds)
6. methimazole (for hyperthyroidism) 5-30 mg PO daily PO daily — Hyperthyroidism (TSH <0.1 + elevated T4/T3); severe → route endo.thyroid-storm.core.v1 (First-line antithyroid; PTU in first-trimester pregnancy; RAI / surgery for definitive; β-blocker for symptomatic control)
7. CPAP for OSA (route sleep medicine) CPAP titrated by polysomnography; auto-PAP alternative CPAP device nightly with sleep — OSA confirmed by polysomnography (AHI ≥5) (First-line for OSA; weight loss adjunct; oral appliance for mild-moderate; positional therapy if positional OSA; addresses fatigue + cardiovascular risk)
8. iron supplementation (for iron-deficiency anemia) Ferrous sulfate 325 mg PO daily or QOD; IV iron if PO intolerant PO / IV daily / QOD — Iron-deficiency anemia (ferritin <30; route symptom.anemia-workup.v1 for full workup) (PO first-line; QOD dosing may improve absorption (Camaschella NEJM 2015 PMID 32513860); IV for malabsorption / intolerance / chronic loss)
9. B12 supplementation (for B12 deficiency) Cyanocobalamin 1000 µg PO daily or IM monthly PO / IM daily / monthly — B12 deficiency (<200 pg/mL) + neuro-psych symptoms (NEJM 2013 PMID 22106456) (PO equivalent to IM for absorption; IM if neurologic symptoms / pernicious anemia / severe deficiency; check intrinsic factor antibodies)
10. pacing for ME/CFS (NOT graded exercise therapy) Patient-determined activity within energy envelope; avoid PEM; planned rest breaks behavioral ongoing — ME/CFS confirmed per IOM 2015 criteria (PMID 25695122) (IOM 2015 / CDC consensus — PACE trial (graded exercise therapy) NOT supported in ME/CFS; pacing within energy envelope; symptom-directed pharmacotherapy (LDN, fludrocortisone for OI); multidisciplinary care)
11. multidisciplinary care for long COVID Per id.covid19.core.v1 multimodal ongoing — Post-COVID fatigue ≥3 mo (PMID 32673060 / 34000130 — verify) (Multidisciplinary approach (rehab, psych, sleep, cardiology, pulm); pacing if PEM; symptom-directed; route id.covid19.core.v1 for full management)
12. deprescribing offending medications N/A — taper or substitute N/A one-time + monitor — Medication-induced fatigue (β-blocker, antihistamine, BZD, opioid, antidepressant, statin) (Substitute with appetite-neutral / activating alternative; carvedilol may have less fatigue than metoprolol; loratadine / cetirizine over diphenhydramine; SSRI / SNRI selection for activating profile)
13. modafinil (for narcolepsy or refractory daytime sleepiness) 100-400 mg PO daily PO AM — Narcolepsy or refractory excessive daytime sleepiness; AVOID in chronic fatigue without sleep disorder (FDA approved for narcolepsy + OSA-related residual sleepiness on CPAP; AVOID off-label use for ME/CFS / depression; CYP3A4 inducer)

Non-pharmacologic actions:
- Sleep medicine referral if STOP-BANG ≥3 or Epworth >10 or witnessed apnea
- Polysomnography for OSA / narcolepsy / RLS / PLMD
- CPAP therapy + weight loss + positional therapy for OSA
- CBT for insomnia (CBT-I) — first-line for chronic insomnia
- Psychiatry referral for depression / anxiety / PTSD
- CBT for depression / anxiety / fibromyalgia
- Multidisciplinary fibromyalgia clinic
- Multidisciplinary ME/CFS clinic + pacing education (NOT graded exercise therapy)
- Multidisciplinary long COVID clinic (cardiology, pulmonology, neurology, psych, rehab)
- Sleep hygiene counseling
- Graded aerobic exercise (NOT for ME/CFS — only deconditioning, fibromyalgia)
- Nutritional counseling + dietitian referral
- Specialty referrals: endocrine, cardiology, nephrology, pulmonology, rheumatology, ID, oncology, GI as indicated
- Social work + community resources if isolation / financial / housing factors
- Vocational rehabilitation if work-impaired (especially ME/CFS / long COVID)
- Smoking cessation + alcohol counseling

Monitoring

Setting (outpatient) monitoring:
- Symptom diary (energy, sleep, mood, pain, cognition, PEM)
- PHQ-9 q4-6 wk if depression-treated
- TSH 6 wk after thyroid therapy adjustment
- HbA1c 3 mo after DM therapy
- CBC at 3 mo if anemia treated
- CPAP compliance + AHI on download
- ME/CFS pacing diary + functional capacity (housebound, bedbound, work-impaired)
- Fibromyalgia response to duloxetine / pregabalin at 4-6 wk
- Long COVID multidisciplinary follow-up q1-3 mo
- Medication deprescribing review
- Lifestyle counseling adherence

Follow-up plan: 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
- Close-out criterion: Long-term plan documented + follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: outpatient — Pattern-anchored chronic fatigue triage (≥6 mo): sleep disorders (~20-30%), depression / psychiatric (~20%), anemia, endocrine (hypothyroid, DM, adrenal), CKD uremic, cardiac low-output, chronic infection (HIV, HCV, TB), malignancy / paraneoplastic, ME/CFS (IOM 2015), fibromyalgia, post-COVID / long COVID, medication-induced, deconditioning, B12 deficiency. Tier 1 → Tier 2 workup; route to disease-specific engine; address cause + symptom-directed (pacing for ME/CFS; CPAP for OSA; SSRI for depression; CBT for fibromyalgia)

Disposition criteria:
- Home (most): stepwise outpatient workup + lifestyle counseling + return precautions
- Outpatient subspecialty: sleep medicine / endocrine / psych / cardiology / nephrology / pulmonary / rheumatology / ID / onc / GI / multidisciplinary clinic (ME/CFS / fibromyalgia / long COVID)
- ED: severe red flags (suicidal ideation, severe thyrotoxicosis, DKA, severe anemia with hemodynamic instability, neuro deficit)
- Inpatient (rare): psychiatric admission for SI, severe medical decompensation, refractory thyrotoxicosis
- Disability evaluation if work-impaired (ME/CFS, long COVID, severe fibromyalgia)

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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
- [SEVERE] 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

Citations

- 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 [PMID:25695122](https://pubmed.ncbi.nlm.nih.gov/25695122/)
- Cited evidence (PMID 26561523) [PMID:26561523](https://pubmed.ncbi.nlm.nih.gov/26561523/)
- Cited evidence (PMID 32673060) [PMID:32673060](https://pubmed.ncbi.nlm.nih.gov/32673060/)
- Cited evidence (PMID 30077542) [PMID:30077542](https://pubmed.ncbi.nlm.nih.gov/30077542/)
- Cited evidence (PMID 19490842) [PMID:19490842](https://pubmed.ncbi.nlm.nih.gov/19490842/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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 — PMID:25695122
  • Cited evidence (PMID 26561523) — PMID:26561523
  • Cited evidence (PMID 32673060) — PMID:32673060
  • Cited evidence (PMID 30077542) — PMID:30077542
  • Cited evidence (PMID 19490842) — PMID:19490842