Tiredness/fatigue

Question 1

Probability diagnosis

Answer 1

Stress and anxiety

Inappropriate lifestyle and psychosocial factors

Depression

Viral/postviral infection

Sleep-related disorders (e.g. sleep apnoea)

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• cardiac arrhythmia
• cardiomyopathy
• incipient CCF

Infection:

• hidden abscess
• HIV/AIDS
• hepatitis B and C/others

Cancer

Other:

• anaemia
• haemochromatosis

Question 3

Pitfalls (often missed)

Answer 3

1. ‘Masked’ depression
2. Food intolerance
3. Coeliac disease
4. Chronic infection (e.g. Lyme disease, TB)
5. Fibromyalgia
6. Lack of fitness
7. Drugs: alcohol, prescribed, withdrawal
8. Menopause syndrome
9. Pregnancy
10. Neurological disorders:

• post-head-injury
• CVA
• Parkinson disease

1. Kidney failure
2. Metabolic (e.g. hypokalaemia, hypomagnesaemia)
3. Chemical exposure (e.g. occupational)

Rarities:

• hyperparathyroidism
• Addison disease
• Cushing syndrome
• narcolepsy
• multiple sclerosis
• autoimmune disorders

Question 4

Masquerades checklist

Answer 4

Depression

Diabetes

Drugs (many)

Anaemia

Thyroid disease, other endocrine (as above)

Spinal dysfunction

UTI

Question 5

Is the patient trying to tell me something?

Answer 5

Highly likely.

Question 6

Key history

Answer 6

Analysis of presenting complaint including associations

Symptoms review especially GI, CV and neurological

Drug hx including self-medication, OTCs, alcohol, antianxiety, antipsychotics, antidepressants

Psychological: stresses, anxiety, depression, sexual problems

Social including relationships, abuse or bullying

Diet and exercise

Question 7

Red flags symptoms

Answer 7

weight change

general discomfort

aches or pains, fever

unusual lumps or bumps (lymph nodes)

bleeding

rashes or pruritus

sleep patterns including snoring, apnoea

Question 8

Key examination

Answer 8

General inspection noting;

• facial features
• skin appearance and colour
• hyperpigmentation
• conjunctivae

Vital signs

Anthropometric measurements

Basic respiratory and cardiovascular

Abd exam with focus on masses and inguinal lymphadenopathy

Urinalysis

Question 9

Key investigations

Answer 9

• FBE
• ESR/CRP
• Blood sugar
• Serum electrolytes, calcium, magnesium
• Kidney function tests
• Liver function tests
• Iron studies
• Faecal occult blood
• Thyroid function tests
• CXR

Question 10

Diagnostic tips

Answer 10

Be alert to depression including masked depression.

Ask pt what they believe is the cause of their tiredness.

Be alert for the classic endocrine traps: hypothyroidism and Addison disease.

Tiredness in absence of red flags is unlikely to have an organic cause.

Investigations are likely to be therapeutic and reassuring rather than diagnostic.

Learn how to undertake a brief, good physical exam and practise effective time management.

Do not overlook a sleep disorder.

Believe pt’s symptoms.