Tiredness

Question 1

Differential diagnoses of Tiredness

Answer 1

Tiredness ddx*
Lifestyle stress* 
Infective Endocarditis* 
DKA* 
Hypothyroidism* 
Zika virus*
Anemia*
Gastroenteritis*
TB*
secondary Adrenal Insufficiency*
Hypoglycemia*
OSA*
Sleep deprivation*
Hepatitis A/E*
Acute Asthma*
Perimenopausal*
Pyelonephritis*

HEMIFADO 
H - Hemochromatosis, Hepatitis 
E - Endocrine - DM, Hypothyroidism 
M - Malignancy - Leukemia, Lymphoma 
I - Infective endocarditis, Infection - HIV, TRAVEL 
F - Chronic fatigue syndrome 
A - Anemia, Atypical pneumonia 
D - Drugs, Depression, Diet 
O - OSA

Question 2

Tiredness - Key History

Answer 2

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

Question 3

Tiredness - Key PE

Answer 3

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

Question 4

Tiredness - Key Investigations

Answer 4

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

Question 5

Tiredness - Diagnostic Tips

Answer 5

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.