{"id":884,"date":"2015-06-04T11:39:07","date_gmt":"2015-06-04T11:39:07","guid":{"rendered":"https:\/\/drcrunch.wordpress.com\/?p=884"},"modified":"2015-06-04T11:39:07","modified_gmt":"2015-06-04T11:39:07","slug":"coping-with-tired-all-the-time-gpvts","status":"publish","type":"post","link":"http:\/\/drcrunch.co.uk\/blog\/2015\/06\/04\/coping-with-tired-all-the-time-gpvts\/","title":{"rendered":"Coping with tired all the time (GPVTS)"},"content":{"rendered":"

\"IMG_0154\"<\/a><\/p>\n

Four facts to get things in perspective:<\/p>\n

    \n
  1. 75% of all complaints of \u2018tired all the time\u2019 self resolve in 4 weeks,<\/li>\n
  2. Two thirds of \u2018tired all the time\u2019 presentations are triggered by acute life stresses.<\/li>\n
  3. At least 50% of the time, you won\u2019t find a diagnosis.<\/li>\n
  4. Fatigue is rarely the sole presenting complaint of malignancy<\/li>\n<\/ol>\n

    Strategy for sifting out the physical causes<\/strong><\/p>\n

    Step 1: Define the type of tiredness
    \nIf you can identify the type, this will help lead the rest of your history.<\/p>\n

    Is it drowsiness? (Think sleep apnea and insomnia)<\/p>\n

    Is it muscular fatigue? (Think neurology)<\/p>\n

    Is it shortness of breath? (Think cardio, respiratory and anaemia)<\/p>\n

    Step 2: How is it affecting the patient?<\/p>\n

    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.<\/p>\n

    Step 3: \u201cIt\u2019s probably not physical, but\u2026\u201d<\/p>\n

    It is reasonable to wait 4 weeks to allow tiredness to self resolve before investigating provided there are no red flags.<\/p>\n

    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.<\/p>\n

    The red flags are:<\/p>\n

      \n
    1. Lymphadenopathy<\/li>\n
    2. Weight loss \u2013 and if so, take a full GI history in case of malabsorbption<\/li>\n
    3. Specific malignancy features. The cancers to consider are the common ones \u2013 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 \u2013 menorrhagia leading to anaemia and amenorrhea from pregnancy are both significant causes of tiredness.<\/li>\n
    4. Joint pains \u2013 is there a rheumatological or vasculitic problem?<\/li>\n
    5. Focal neurology \u2013 MS or tumour<\/li>\n
    6. Systemic infection \u2013 is there TB, glandular fever (or post glandular fever) or perhaps Lyme disease (which does exist in England!)<\/li>\n<\/ol>\n

      Step 4: What non physical elements could be driving this?<\/p>\n

      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 \u2018Are you stressed?\u2019<\/p>\n

      Once you have rapport, explore life events at work and home. Take a depression history when it is appropriate \u2013 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?<\/p>\n

      Make sure you have identified alcohol and drug use, especially cannabis use in young people (demotivation is a common effect of cannabis).<\/p>\n

      Step 5: Examination<\/p>\n

      This will be focused on the leads from your history, but should always include pulse, blood pressure and BMI.<\/p>\n

      Step 6: The plan<\/p>\n

      Less than 3% of tests of anaemia and thyroid function for tiredness are positive. The other physical causes are even rarer e.g. Addison\u2019s, coeliac, diabetes etc.<\/p>\n

      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\u2019s worth bearing in mind that nearly 5% of all tests ordered by GPs are for tiredness. That\u2019s a pretty big use of resources for tests that are rarely positive.<\/p>\n

      NICE guidelines do also suggest coeliac screening for unexplained tiredness.<\/p>\n

      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)<\/p>\n

      If there is no resolution by 4-6 months, consider chronic fatigue syndrome.<\/p>\n

      Step 7: Management<\/p>\n

      I\u2019ll write this next week. I\u2019m too tired.<\/p>\n

      Sources:<\/p>\n

      1. BMJ – http:\/\/www.bmj.com\/content\/341\/bmj.c4259?sso=<\/p>\n

      2. Patient UK – http:\/\/patient.info\/doctor\/fatigue-and-tatt<\/p>\n

      3. NICE CKS – http:\/\/cks.nice.org.uk\/tirednessfatigue-in-adults#!backgroundsub:4<\/p>\n

      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<\/p>\n","protected":false},"excerpt":{"rendered":"

      Four facts to get things in perspective: 75% of all complaints of \u2018tired all the time\u2019 self resolve in 4 weeks, Two thirds of \u2018tired all the time\u2019 presentations are…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"spay_email":"","footnotes":"","jetpack_publicize_message":""},"categories":[1],"tags":[],"class_list":["post-884","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"jetpack_featured_media_url":"","jetpack_publicize_connections":[],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p9zRNY-eg","jetpack_likes_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts\/884","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/comments?post=884"}],"version-history":[{"count":0,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts\/884\/revisions"}],"wp:attachment":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/media?parent=884"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/categories?post=884"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/tags?post=884"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}