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

Background

• 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

History

• 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)

Examination

• 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

Investigations

• 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

Causes

• 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)