Approach to Fatigue in Primary Care: A Practical Diagnostic Framework for General Practitioners, 2026, Elbaroumi

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Open Access Review Article

Approach to Fatigue in Primary Care: A Practical Diagnostic Framework for General Practitioners

Omar Elbaroumi

1 1. General Practice, NHS Independent Practice, Colchester, GBR

DOI: 10.7759/cureus.108764

Corresponding author: Omar Elbaroumi, omarelbaroumi@hotmail.com

Abstract

Fatigue is one of the most common presenting complaints in primary care and poses a significant diagnostic challenge due to its multifactorial aetiology. While the majority of cases are benign and self-limiting, fatigue may also represent an early manifestation of serious underlying pathology. This review distinguishes between acute fatigue, typically transient and associated with intercurrent illness or lifestyle factors, and chronic fatigue, defined as fatigue persisting for six or more weeks, which is more likely to be multifactorial in origin.

This narrative review aims to provide a practical and structured diagnostic framework for general practitioners to evaluate and manage fatigue effectively in the primary care setting.

A narrative review of the literature was conducted using PubMed and Google Scholar. Searches were limited to articles published in English from 2010 onwards. Search terms included "fatigue," "primary care," "chronic fatigue," "myalgic encephalomyelitis," "post-viral fatigue," "sleep disorders," and "functional somatic syndromes." Seminal references predating 2010 were retained where no suitable replacement was available. This review did not employ a formal systematic search strategy, and no risk-of-bias assessment was performed, consistent with the narrative review format.

Fatigue arises from a wide range of physical, psychological, and lifestyle-related causes, best understood through a three-tier classification: primary/idiopathic, secondary, and psychosocial. A systematic approach incorporating thorough history-taking, focused clinical examination, and judicious use of investigations is essential. Identification of red flag symptoms is critical to exclude serious conditions, including malignancy and chronic infections.

A structured, patient-centred approach enables general practitioners to manage fatigue effectively while minimising unnecessary investigations and ensuring timely identification of serious disease.

Categories: Family/General Practice, Internal Medicine, Preventive Medicine

Keywords: chronic fatigue, diagnosis, family medicine, fatigue, long covid, nice guidelines, primary care

Review began 04/27/2026 Review ended 05/06/2026 Published 05/13/2026
 
Fatigue is a frequently encountered symptom in primary care, accounting for a substantial proportion of general practitioner consultations [1,2]. It represents a significant burden on healthcare systems
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It actually imposes no burden on healthcare systems, and that's part of the problem, because their workplace is the only place they can notice things and direct health care expenses make up the near totality of financial considerations about disease burden. If it did impose a burden, it would compel action. Instead, choices were made to cast it out entirely out of health care, out of medicine, and even out of most of the secondary systems that deal with disability.

Normally the financial burden of so many people being unable to work, being so costly, would compel action, but by crafting a system that "takes care of the problem", eliminating almost all direct costs (at the expense of increasing indirect costs), the problem can never be solved because its impact has essentially been swept entirely under a giant rug.
Mental health conditions, particularly depression and anxiety, are frequently associated with fatigue and may complicate both diagnosis and management
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Overlapping questions yield false overlapping answers. Normally professionals want to avoid or minimize that. Here they are instead maximized, hence widespread systemic failure that has not produced a single bit of actionable, useful knowledge.

Their distinction of primary/idiopathic and secondary categories seem arbitrary, leaning about 99% on the idiopathic part. There is no reason to frame the excessive fatigue in ME/CFS as any more primary than in MS or anemia, other than no one understands why that is, but this is also true of those in the secondary categories. The only real difference is the recognition of an acknowledged primary cause, a disease, compared to cases where it's not identified. This is not a property of the illnesses or the patients, but a property of medical knowledge.
ME/CFS, in particular, is associated with post-exertional malaise, a worsening of symptoms following physical or mental exertion, which has important implications for management and distinguishes it from other causes of fatigue. A multidisciplinary approach involving medical, psychological, and rehabilitative support is typically required [5,9].
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"Required" is doing a lot of work here. It's ineffective, and so has no basis for being recommended, let alone required. Reference 5 is the 2021 NICE guideline, which obviously requires no such thing, in fact advises against this, and 9 is Afari N, Buchwald D: Chronic fatigue syndrome: a review. (Am J Psychiatry. 2003), for some reason. (Didn't seem to have been posted, so thread here: https://www.s4me.info/threads/chronic-fatigue-syndrome-a-review-2003-afari-buchwald.50325/).
Psychosocial causes are highly prevalent and frequently under-recognised.
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They are always at best speculative and massively over-attributed.
CBT is evidence-based for chronic fatigue of any cause
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Reference is yet another old psychosomatic article: https://journals.lww.com/bsam/abstr...ations_between_unexplained_fatigue_and.7.aspx.
Graded exercise is contraindicated in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); tailor to the underlying cause [3,5]
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Somehow the references for this are 3): Sharpe M, Wilks D: Fatigue. BMJ. 2002, and 5): 2021 NICE guideline.

Hard to say about the quality of what this review says about non-ME/CFS and non-idiopathic chronic fatigue because it's very confused about ME/CFS, in ways that make the rest highly suspicious, but a casual reader with medical training would obviously not see that. What a mess. Someone trained in medicine has almost zero chance of being able to rely on credible knowledge about this when everything about it is a mass of confusion at best.
 
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