Tiredness/chronic fatigue

Probability diagnosis

Stress and anxiety

Inappropriate lifestyle and psychosocial factors

Depression

Viral/postviral infection

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

Serious disorders not to be missed

Vascular:

• cardiac arrhythmia

• cardiomyopathy

• incipient CCF

Infection:

• hidden abscess

• HIV/AIDS

• hepatitis B and C/others

Cancer

Other:

• anaemia

• haemochromatosis

Pitfalls (often missed)

‘Masked’ depression

Food intolerance

Coeliac disease

Chronic infection (e.g. Lyme disease, TB)

Fibromyalgia

Lack of fitness

Drugs: alcohol, prescribed, withdrawal

Menopause syndrome

Pregnancy

Neurological disorders:

• post-head-injury

• CVA

• Parkinson disease

Kidney failure

Metabolic (e.g. hypokalaemia, hypomagnesaemia)

Chemical exposure (e.g. occupational)

Rarities:

• hyperparathyroidism

• Addison disease

• Cushing syndrome

• narcolepsy

• multiple sclerosis

• autoimmune disorders

Masquerades checklist

Depression

Diabetes

Drugs (many)

Anaemia

Thyroid disease, other endocrine (as above)

Spinal dysfunction

UTI

Is the patient trying to tell me something?

Highly likely.

Key history

• Analysis of presenting complaint including associations

• General questions covering red flags, weight change, general discomfort, aches or pains, fever, unusual lumps or bumps (lymph nodes), bleeding, rashes or pruritus, sleep patterns including snoring, apnoea

• Symptoms review especially gastrointestinal, cardiovascular and neurological

• Drug history including self-medication, OTCs, alcohol, antianxiety, antipsychotics, antidepressants

• Psychological: stresses, anxiety, depression, sexual problems

• Social including relationships, abuse or bullying

• Diet and exercise

Key examination

General inspection noting facial features, skin appearance and colour, hyperpigmentation, conjunctivae

• Vital signs

• Anthropometric measurements

• Basic respiratory and cardiovascular

• Abdominal examination with focus on masses and inguinal lymphadenopathy

• Urinalysis

Key investigations

• FBE

• ESR/CRP

• Blood sugar

• Serum electrolytes, calcium, magnesium

• Kidney function tests

• Liver function tests

• Iron studies

• Faecal occult blood

• Thyroid function tests

• CXR

Diagnostic tips

• Be alert to depression including masked depression.

• Ask the patient 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 examination and practise effective time management.

• Do not overlook a sleep disorder.

• Believe the patient’s symptoms.