Red flag symptoms: Excessive tiredness

The numerous differential diagnoses will test a GP in a 10-minute consultation. By Dr Anna Greenham

Reg flag symptoms checklist
  • Weight change
  • Change in bowel habit
  • History of bleeding
  • Cough or shortness of breath
  • Polyuria

      
Tiredness may have a psychological cause (photograph: SPL)

Tiredness is a very common presenting symptom in general practice. The differential diagnosis is so broad that a full list would be impractical. The skills of a true generalist, including instinct and experience can be put to the test, especially in a 10-minute consultation.

In the majority of cases it will not be possible to find a physical cause, psychological ones being more likely. However, there are many potentially serious causes which should be considered (see list below).

Assessment

A good history is essential. Establish the duration and intensity of the tiredness. Is the patient sleeping well? Does activity make their tiredness worse?

A systemic review may reveal weight change, change in bowel habit, shortness of breath, snoring, bleeding, polyuria or other relevant factors. Enquire about symptoms of low mood or anxiety.

Ask about drugs and alcohol. Are there any relevant social factors? Could prescribed medications be implicated?

In the absence of relevant history it is unusual for physical examination to add much. However it is wise to check for pallor, arrhythmias, lymphadenopathy, masses or other obvious signs of systemic disease.  

It may be necessary to perform some basic tests, guided by the history. These could include FBC, U&Es, LFT, TFT, glucose, HIV, tissue transglutaminase, ESR and monospot. Chest X-ray, scans and tumour markers (guided by history) may be indicated, but often are not.

Management

Many of the significant physical causes will produce some abnormality on testing. In the majority of cases, all results will be normal. However, normal tests can be reassuring for physician and patient alike.

Before trying to reassure the patient it is necessary to establish what they fear may be going wrong with their health. It might not be what you expected.

The impact of psychological causes should not be underestimated. The patient may initially be disappointed not to have a physical reason to hang their tiredness on. An empathetic approach may be needed to help the patient move towards a more psychological agenda.

In some people fatigue can become chronic. In the absence of other causes it may be worth considering ME/chronic fatigue syndrome in your differential.

  • Dr Greenham is a salaried GP in Gateshead
Possible causes
  • Metabolic – diabetes, renal failure, liver failure.
  • Cardiac – heart failure, arrhythmias.
  • Infections – including post-viral, glandular fever, TB, HIV, endocarditis.
  • Endocrine – hypothyroid, hypopituitary, Addison’s disease.
  • Anaemia – bleeding, dietary, malabsorption.
  • Malignancies.
  • Rheumatological – inflammatory arthritis, systemic lupus erythematosus, polymyalgia rheumatica.
  • Neurological – MS, motor neurone disease.
  • Psychiatric – depression, anxiety.
  • Sleep disorders.
  • Lifestyle – obesity, alcohol.
  • Iatrogenic – medications.

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