Tiredness
Persistent tiredness or physical fatigue with no obvious cause is a common complaint. It is normal to feel tired at times, e.g. after working long hours, unaccustomed exertion or sleepless nights. It is important to differentiate between tiredness due to excessive normal activities and tiredness due to disease.
History
The history is most important in the diagnosis. It is necessary to define exactly what is meant by tiredness or fatigue. Fatigue is sometimes known as ‘tired all the time syndrome’. Take a full history to decide whether tiredness is of a physical, psychological or social nature. Note the duration of the problem. Is it getting worse? Was there any precipitating factor? Ask about previous levels of energy and how this compares with the present. Has the patient noticed any other changes, e.g. in appetite, increased urine output or thirst or sleep disturbances? Has there been any recent change in medication, e.g. beta blockers causing lethargy? Chronic fatigue syndrome is more common in teenagers and young adults, especially students. It is uncommon after early middle age. Depression is more common in women aged 30 and over. In middle-aged and elderly people the symptoms of chronic fatigue are more likely to represent underlying organic disease.
A history of previous illnesses such as infectious mononucleosis or influenza should be sought. Ask about bereavement. Weight loss may suggest malignancy or depression with episodes of fever, suggesting chronic infection, e.g. TB. Cold intolerance suggests myxoedema. Heat intolerance suggests thyrotoxicosis. In chronic fatigue syndrome, the illness may fluctuate from week to week and may occasionally be relieved by rest. In malignancy, the symptoms are progressive and deterioration occurs. The same is true for endocrine disorders. Tiredness associated with depression may fluctuate considerably with changing circumstances. Ask about the patient’s lifestyle. Is there an excessive consumption of alcohol? Alcohol itself may cause tiredness but if alcohol is being used as a coping mechanism for stress-related illness, it is likely to aggravate rather than alleviate the problem. Ask about recreational drugs. Ask about work. Have the patient’s work circumstances changed and are they working very long hours together with home commitments. Take a full neurological history to exclude conditions such as multiple sclerosis and myasthenia gravis. Ask about excessively hard training in runners, weight trainers and athletes. The over-training syndrome may lead to persistent fatigue. Carbon monoxide poisoning is rare but does occur occasionally and it is appropriate to take a history about any change of health of other members of the household as carbon monoxide poisoning would be likely to affect them also.
Examination
Meticulous examination is essential. Look at the patient. Is the patient someone who looks systemically unwell or has lost weight? Is there any evidence of anxiety, tiredness or sleep deprivation? Pyrexia may indicate the presence of systemic illness, e.g. TB, HIV. In chronic fatigue syndrome and in depression, there will be no abnormal physical signs. A slight tachycardia may occur with anxiety and stress. Check for clinical signs of anaemia. Check for signs of hyperthyroidism or hypothyroidism. Anaemia and thyrotoxicosis will produce a bounding, hyperdynamic pulse. In malignancy, there may be enlarged lymph nodes or the liver may be palpable. A detailed neurological examination is required to exclude neurological disease as a cause of symptoms. Postural hypotension may occur in Addison’s disease.
