Tiredness

During a routine appointment a 48 year old woman tells you that she feels tired all the time. You know that she has changed jobs recently and that her daughter has recently returned to university.

What issues you should cover

Reasons for consulting

Tiredness is a common presenting symptom. Often the cause may be physical; diseases such as hypothyroidism, autoimmune disease, liver or kidney disease, or even cancer may result in tiredness. Tiredness is, however, more often due to depression or the stresses of life circumstances.

Tiredness may not be the main focus of her concerns, and she may only offer it as an initial symptom to see whether you are sympathetic and interested. Her main issue may be a more sensitive one, such as the menopause or the stress of recent events in her life. Patients may consider tiredness to be a more legitimate symptom to bring to a doctor than, say, unhappiness. Although such a patient may elicit “heartsink” feelings in the doctor, this symptom should provoke careful evaluation, and managing this consultation effectively could enhance the doctor-patient relationship and help avoid a future series of unproductive consultations.

Defining tiredness

Tiredness is not a specific term and patients may use it to cover a number of symptoms. Lack of motivation and low energy are features of depression. Fatigue and weakness may be the result of chronic illness. Daytime sleepiness may be due to obstructive sleep apnoea or sedating treatment, including non-prescription drugs such as antihistamines. Drowsiness and headaches in the winter months may be symptoms of carbon monoxide poisoning. Fatigue lasting more than six months that isn't alleviated by rest and that is associated with muscle pain and memory impairment may be chronic fatigue syndrome.

Physical examination

An examination is unlikely to yield more information unless the history indicates a specific diagnosis, but it may reassure the patient and give you time to consider the next steps. Look in particular for signs of pallor, lymphadenopathy, thyroid disease, and heart failure.

Tiredness: symptoms, diagnoses, and investigations

Symptoms

• Fatigue

• Weakness

• Sleepiness

Diagnoses

• Depression

• Obesity; obstructive sleep apnoea

• Poor sleep pattern; hard work; stress

• Treatment with a sedative; caffeine withdrawal

• Anaemia; iron deficiency; cancer; renal disease; liver disease; heart failure; thyroid disease; diabetes; autoimmune disease

Investigations

• Full blood count

• Erythrocyte sedimentation rate

• Liver and kidney function

• Blood glucose

• Thyroid function

• Urinalysis for protein and glucose

• Consider monospot, endomysial antibody, or antinuclear antigen testing, chest radiography, or other tests as guided by history and examination

What you should do

• Take this symptom seriously. Patients experience more tiredness than they report to doctors, so it is likely that this symptom is important to her.

• Ask whether she means she is “weak and lacking energy” or whether she is “drowsy and not refreshed by her sleep.”

• Two questions may be used to screen for depression (with 97% sensitivity): “During the past month have you often been bothered by feeling down, depressed, or hopeless?” “During the past month have you often been bothered by little interest or pleasure in doing things?” A positive answer to either question suggests depression.

• Try to determine her concerns regarding her “tiredness.” Explore whether she links her symptoms to any distressing circumstances in her life. There is little point reassuring her unless her concerns have been explored. This could just compound her worries about previously unconsidered possibilities.

• Consider whether investigation may be useful. It may diagnose or exclude a physical illness, which may reassure you and the patient. Investigations may also be a prelude to a follow-up consultation to allow further exploration of an emotional or social concern. Decide whether she needs investigation for illness, reassurance of normality, or support at a difficult time.

• Often an innocent physiological explanation can be offered confidently, such as at times of fast growth (as with teenagers or during pregnancy).

• Empathising with a distressing life predicament can be remarkably helpful, and your advice and interest will be remembered.

• If you think she may be depressed, arrange another consultation soon to consider treatment options.

• Ensure that she has clear instructions about follow-up and when to seek further advice, so that if she has organic disease she does not slip through the net and diagnosis isn't delayed.