• usually self limiting

• Usually fit into 3 different but overlapping groups:

  • Lifestyle

  • Psychosocial

  • Physical

  • (Unkown)

Lifestyle

• Tiredness common in people who have undergone signifiant life events

  • take seriously

    • increase risk of serious illness in following 2 years

• Occupation/study

  • complex relationhsip between occupation and other lifestyle factors, psychosocial issues and physical health

• Diet

  • extremes can cause tiredness

    • particularly iron deficiency

  • but meals that too heavy, too often

  • ‘fad diets’

  • excesses of particular dietry ingedients

    • caffeine, guarana, sugar

• EtOH and recreational drugs

• Exercise

  • extremes of exercise can contribute

    • non-fasting hypoglycaemia

    • iron deficiency

    • susceptibility to recurrent infections

  • underexercise

    • persistent lassitude

• Sleep disorders

  • sleep requirements biologically determined

    • varies between individuals

  • Primary insomnia

  • Secondary insomnia

    • associated with physical cause

      • night pain

      • breathlessness

      • psychological

        • depression

        • anxiety

  • OSA

    • snoring

    • daytime sleepiness

    • witnessed apnoea

    • nocturnal choking

  • central sleep apnoea

Psychosocial factors

• often overlap with lifestyle

• Screening questions for depression (reliably)

  • ” During the last month, have you often been bothered by feeling down, depressed or hopeless?”

  • ”During the last month, have you often been bothered by having little interest or pleasure in doing things?”

• PHQ-9 may assist

Physical health

• Co-morbidities

  • Diabetes

  • Rheumatoid arthritis

  • cancer

  • COPD

  • asthma

  • heart failure

  • check any chronic conditions under good control

• medications

  • psychoactive drugs

  • antihypertensives

  • hormone preparations

• New conditions

  • Type 2 DM

  • Addison’s disease

Framework:

Step 1: Define the problem from patient’s viewpoint

• What does paient mean by tiredness?

• Is tiredness only issue?

• How is it affecting life?

• What do they believe is causing it?

• What are their concerns?

Step 2: Focused symptom review

• red flags

• women

  • menstural symptoms

• elderly

  • weight loss

  • appetite

  • bowel disturbance

• smoker

  • cough

Step 3: Focused examination

Step 4: Focused lab tests

\<50yo without other risk factors

• CBC

• Ferritin

• searching for:

  • iron deficiency

  • macrocytosis

  • significant infections

  • leukaemia

>50yo lasting > 1mo

• CBC

• CRP

• Ferritin (iron saturation)

• LFT

• Creatinine

• Electrolytes

• Calcium, phosphate

• TSH

• Fasting glucose (HbA1c)

• urinalysis

• ANA

Further considerations:

• EBV

  • unlikely to be helpful

• Haemochromatosis

  • no more likely to be tired compared to rest of gneeral population

• Vit b12/folate

  • rare to find deficiency without anaemia

  • reserve until macrocytosis

  • folic acid eficiency can also be caused by malabsorption

    • most often caused by low dietary intake

    • destroyed during cooking

    • low intake associated with old age, poverty, alcoholim and diet fads

    • no need to test red cell folate

  • B12

    • most common = malabsorption

      • pernicious anaemia

      • achlorhydria

    • take 2 years to deplete

    • women taking oral contraceptive = flasely low vit b12 concentrations = low cobalamin - carrier protein