HISTORY:
Fatigue for
Severity: , impact on daily activities
Pattern: , worse during the
Worsening factors:
Treatments tried: ,
, over ,
Additional symptoms:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , , , , , , ,
- Urinalysis
- ECG
- Chest X-ray
- Sleep study
- Lifestyle modifications: , , ,
-
-
-
- Multi-vitamins
- Referral to psychologist
- Referral to sleep specialist
- Referral to endocrinologist
- Follow-up in
- Return if fatigue worsens or if new symptoms develop such as weight loss, fever, or persistent sleep disturbances