Four facts to get things in perspective:
- 75% of all complaints of ‘tired all the time’ self resolve in 4 weeks,
- Two thirds of ‘tired all the time’ presentations are triggered by acute life stresses.
- At least 50% of the time, you won’t find a diagnosis.
- Fatigue is rarely the sole presenting complaint of malignancy
Strategy for sifting out the physical causes
Step 1: Define the type of tiredness
If you can identify the type, this will help lead the rest of your history.
Is it drowsiness? (Think sleep apnea and insomnia)
Is it muscular fatigue? (Think neurology)
Is it shortness of breath? (Think cardio, respiratory and anaemia)
Step 2: How is it affecting the patient?
Tiredness is really common in the general population. Only 1 out of 400 people who have tiredness actually see their GP. It is important to find out what brought this patient in. The tipping point is often a change in functional status e.g. struggling at work, unable to go to gym, sleeping in all morning etc. Documenting the functional status allows you to monitor progress.
Step 3: “It’s probably not physical, but…”
It is reasonable to wait 4 weeks to allow tiredness to self resolve before investigating provided there are no red flags.
It is also reasonable to attribute the tiredness to a well defined life stress event provided there are no red flags and the patient has a defined time frame for returning.
The red flags are:
- Lymphadenopathy
- Weight loss – and if so, take a full GI history in case of malabsorbption
- Specific malignancy features. The cancers to consider are the common ones – lung, breast, GI and gyane. This means you would actively ask for haemoptysis, cough, dysphagia, change in bowel habits/bleeding, breast lumps and unexpected PV bleeding. In fact, a good menstrual history is essential in all women – menorrhagia leading to anaemia and amenorrhea from pregnancy are both significant causes of tiredness.
- Joint pains – is there a rheumatological or vasculitic problem?
- Focal neurology – MS or tumour
- Systemic infection – is there TB, glandular fever (or post glandular fever) or perhaps Lyme disease (which does exist in England!)
Step 4: What non physical elements could be driving this?
Social history is the next thing after the red flags. The advantage of doing red flags/physical symptoms first is that the patient is more likely to feel you are taking them seriously than if you go straight to ‘Are you stressed?’
Once you have rapport, explore life events at work and home. Take a depression history when it is appropriate – perhaps after hearing about a life event, you could mention that a lot of people might feel down after that, and has this patient noticed anything like that?
Make sure you have identified alcohol and drug use, especially cannabis use in young people (demotivation is a common effect of cannabis).
Step 5: Examination
This will be focused on the leads from your history, but should always include pulse, blood pressure and BMI.
Step 6: The plan
Less than 3% of tests of anaemia and thyroid function for tiredness are positive. The other physical causes are even rarer e.g. Addison’s, coeliac, diabetes etc.
If you are going to investigate, the first line panel can be FBC, ESR, TFTs and random glucose. There is a fuller panel suggested on NICE CKS, but according to the BMJ article on primary care investigations these four tests are almost as good. And it’s worth bearing in mind that nearly 5% of all tests ordered by GPs are for tiredness. That’s a pretty big use of resources for tests that are rarely positive.
NICE guidelines do also suggest coeliac screening for unexplained tiredness.
If there is no resolution by 3 months, you can send off the second line panel (http://cks.nice.org.uk/tirednessfatigue-in-adults#!diagnosissub:4)
If there is no resolution by 4-6 months, consider chronic fatigue syndrome.
Step 7: Management
I’ll write this next week. I’m too tired.
Sources:
1. BMJ – http://www.bmj.com/content/341/bmj.c4259?sso=
2. Patient UK – http://patient.info/doctor/fatigue-and-tatt
3. NICE CKS – http://cks.nice.org.uk/tirednessfatigue-in-adults#!backgroundsub:4
3. BMJ Learning – http://learning.bmj.com/learning/modules/flow/expired.html?moduleId=10030395&status=LIVE&locale=en_GB&_flowId=JIT&page=5&action=start&shouldStartAtQuestionSection=false&sessionTimeoutInMin=90
I was that needle in the haystack. TATT is kind of overwhelming in that a significant proportion of our consultations are for just that, and mostly it ends up being life events etc with no underlying physical cause, but try not to be too TATT yourself that you stop paying attention to other TATT patients. R&R needed for doctors too.