Lethargy, Fatigue and ‘Tired All The Time’ (TATT)


  • Extremely common presentation to GP (5-7% of consultations)
  • Tiredness/fatigue is a subjective symptom and, in most cases, will not be pathological but a physiological response
    • Most (up to 75%) are isolated cases which have no follow up
  • Isolated tiredness can be difficult to assess; there are many associated factors and symptoms which could potentially cause tiredness
  • Chronic symptoms are defined as >6 months


  • Define what the patient means by tired and of their ICE (why do you think you’re tired?)
    • Sleepiness may indicate sleep apnoea, muscle weakness may indicate an autoimmune disorder/neuromuscular cause
  • Ask about onset, duration and timing
    • What was the patient like before?
    • Short history and abrupt onset suggest viral cause or potentially onset of DM, myocardial ischaemia, toxins, drugs, post-traumatic cause;
    • protracted course could suggest functional/emotional cause; uraemia; heart failure, liver failure, DM, electrolyte or hormone imbalance, anaemia
    • Was there an incident that triggered it?  Any family/house members been ill recently?
    • Ask about pattern
      • Fatigue on exertion which goes away with rest suggests organic cause
      • Worse in the morning suggests emotional cause/depression
  • Ask about associated symptoms
    • Breathlessness
    • Muscle weakness
    • Weight loss/gain
    • Anorexia/loss of appetite, fever, night sweats
    • Headache, muscle/joint pain, sore throat; features of systemic inflammatory diseases
    • Haemoptysis; dysphagia; rectal bleeding; breast lump; postmenopausal bleeding; localising neurological symptoms
    • Chronic pain
    • Polyuria/polydipsia
    • Change in bowel habit
    • Menstrual changes
    • Mood changes
    • Difficulty with memory/cognition
  • Ask about sleeping pattern
    • Early morning wakening/unrefreshing sleep suggests depression potentially
    • Daytime somnolence; interrupted sleep and breathless wakening at night could be sleep apnoea
    • Ask also about exercise, activity
  • Past medical and psychiatric history
    • Ask also about change in medications
  • Ask about social history
    • Alcohol
    • Smoking
    • Drug taking (including OTC/CAM/illicit)
    • Occupation (consider shift patterns)


  • Ideally, a full clinical examination of all major organ systems should be carried out (this may not be possible in the time period of an average consultation (particularly GP)- but examination can be guided by the history as appropriate)
  • Look particularly for lymphadenopathy


  • First line
    • Routine TATT blood tests include
      • FBC; ESR/PV; TFTs; Glucose; and some antibody tests e.g. TTG IgA for Coeliac
    • In patients >60
      • LFTs and U&Es are also done (often also in <60s also); Bone biochemistry and vit D;
    • Iron studies
    • Monospot test
    • If at risk, HIV and Hepatitis serology
    • Consider pregnancy test
  • In patients with >3 months symptoms, 2nd line tests should be offered to exclude possible diagnoses
    • Urinalysis (protein, blood, glucose)
    • FBC, U&E, LFT, TFT, ESR/PV, CRP, Glucose, Creatinine, Calcium, Creatinine Kinase, IgA
  • Consider testing also for chronic bacterial or viral infections


  • Psychological/Psychosocial
    • Depression, Anxiety, Stress
  • Physical
    • Anaemia, DM, Glandular fever, Malignancy, Thyroid disease, renal disease, liver disease, autoimmune disease
  • Physiological
    • Pregnancy, breastfeeding, inadequate rest/sleep, excess exercise/activity
  • Mixed
  • Unknown (Chronic Fatigue syndrome)

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