Red flag symptoms: Tiredness

Dr Barney Tinsley highlights the important issues to look for with this common symptom.

Tiredness or so-called 'tired all the time' (TATT) is a very common presenting complaint in general practice. It is often of insidious onset, with no obvious precipitating cause.

Tierdness is a common symptom

Patients tend to feel generally lethargic, although actual malaise is less common. There may be organic presenting factors such as weight changes (especially weight loss), overt blood losses or GI blood loss.

Red flag symptoms
  • Acute onset or long-term duration
  • Weight change
  • Change in appetite or sleep pattern
  • Altered bowel habit or urinary symptoms
  • Blood loss
  • Shortness of breath
  • Jaundice

A change in bowel habit, urinary symptoms, shortness of breath and jaundice might be among more obvious presenting symptoms.

Also consider affective symptoms such as mood, appetite, sleep pattern and so on, and situational factors, like home or work-life stressors. Take a complete history.

Identifying an organic cause is often achieved by the clinical history. An ordered systems review is recommended.

Particular attention should be paid to more common systems, for example thyroid, renal, hepatic and cardiac causes (see box below). The possibility of malignancy should always be considered, as should underlying disease or chronic anaemia.

Blood tests are often therapeutic rather than diagnostic.

It is useful to advise patients with no obvious organic cause that initial blood tests often are reassuring rather than indicative of an underlying problem.

Recommended first-line tests are as follows: FBC, iron level, ESR, U&Es, LFTs, TFTs and fasting glucose. Coeliac antibodies and serum tissue transglutaminase should also be considered, along with a urine dipstick and ECG, as necessary.

Depressive illness
Stress-related or true depressive illnesses account for a significant proportion of ultimate diagnoses. Clinicians might use a patient health questionnaire-9 (PHQ-9), or other appropriate screening tool to examine patients for underlying depression, as well as open questions regarding other common stressors.

Referral for specialist counselling may be appropriate.

Rare causes
Rarer organic causes include chronic infections, such as TB, hyperthyroidism, neurological disease (MS, motor neurone disease, myasthenia gravis), Addison's disease, or connective tissue disease (polymyalgia rheumatica, rheumatoid arthritis and SLE).

These conditions are likely to require referral. Patients presenting with 'red flag' symptoms should be referred under the two-week wait protocol.

  • Dr Tinsley is a GP Partner in Harrogate, North Yorkshire
Possible causes
  • Thyroid disease
  • Anaemias, especially iron-deficiency
  • Post-viral fatigue, including ME
  • Renal, cardiac or liver disease
  • Coeliac disease
  • Medications, eg beta-blockers, diuretics
  • Substance misuse
  • Malignancy

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