The correct answer is A. The initial evaluation of a patient with fatigue includes a thorough history and physical examination, a complete blood count, and a biochemical profile. These will evaluate the patient for causes of fatigue such as anemia, uremia, diabetes mellitus, adrenal insufficiency, hypokalemia, hyponatremia, and hepatitis. If these tests are negative, thyroid function tests and the evaluation for an infection and an occult malignancy are indicated. If all studies are negative, a nutritional deficiency, depression, a chronic viral infection, or chronic fatigue syndrome should be considered. Even if chronic fatigue syndrome is suspected, routine laboratory studies must be performed to exclude other causes of her symptoms.
A chest x-ray (choice B) is used to evaluate a cardiopulmonary process. Since this patient does not have symptoms that seem directly related to these systems, a chest x-ray is not the most appropriate next step. It may be indicated in the future because fatigue may be associated with cardiopulmonary processes, but a biochemical profile should be ordered next.
Fluoxetine (choice C) is used to treat depression and while it is possible that this patient is depressed, she requires an evaluation with laboratory studies for her fatigue. She does not complain of any other symptoms of depression, such as difficulty sleeping, change in concentration, guilt, worthlessness, and suicidal ideation.
Reassurance and a scheduled follow-up visit in 1 week (choice D) is inappropriate. An evaluation for her fatigue is indicated because a 3-month history of "tiredness" is not normal.
Referring her to a psychiatrist (choice E) may be indicated in the future, but at this time she requires an evaluation for fatigue.
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