Medically Fit For Exams
Medically Fit For Exams

Tiredness history taking

 

  • Wash hands and introduce yourself
  • Check the patient’s name and DOB
  • Ask if it’s okay to talk to the patient before they see the doctor

 

History of presenting complaint

Differential diagnoses

Diabetes

Anaemia

Sleep apnoea

Stress/depression

Cancer

Hypothyroidism

Organ failure: heart, liver, kidney

Inflammatory disease eg RA, IBD

Viral illness/post-viral fatigue

Chronic fatigue/fibromyalgia

  •  ‘What has brought you in today?’
  • ‘Tell me more about your tiredness’
  • If the patient doesn’t mention, ask about the following:
    • Stress
      • Work
      • Family/relationships
    • Sleeping
      • Simple cause for tiredness
      • Sleep apnoea?
      • Anxiety/depression
    • Diabetes screen
      • Increase in urination/drinking/nocturia
      • Weight loss
    • Viral illness
      • ‘Have you had any tummy bugs or coughs or colds recently?’
    • Depression
      • How has your mood been recently?
      • Have you noticed a lower mood than normal?
    • Anaemia screen
      • Do you have heavy periods?
      • Noticed blood in the stool?
      • Red meat and green veg intake?
    • Cancer
      • Weight loss
      • Change in bowel habits
      • Any new lumps and bumps
    • Inflammatory disease
      • Joint and muscle pain
      • Abdominal pain
      • Diarrhoea
    • Hypothyroidism
      • Weight gain despite reduced appetite
      • Feeling the cold more
      • Constipation
    • Heart failure
      • Pitting leg oedema
      • SOB on exertion
      • Cough with frothy sputum
      • Paroxysmal nocturnal dyspnoea
      • Extra pillows at night for breathing
    • Renal failure
      • Anorexia
      • Itching
      • Nausea
    • Liver failure
      • Oedema
      • Jaundice
  • Explore any of these symptoms as they arise
    • Onset
    • Time scale – constant or intermittent, progressive?
    • Severity
    • Explore risk factors for any disease that your screening questions pick up
  • Systems enquiry – ask any questions that haven’t already been covered by your screening questions
    • Headaches, faints, fits
    • Visual changes
    • Cough
    • SOB
    • Chest pain
    • Abdominal pain
    • Change in bowel habits
    • Change in waterworks
    • Aches and pains
  • Summarise what they have told you and check that it is correct

 

Past medical history

  • Do they have any medical problems that they see a doctor about
  • Have they had any problems with low mood or anxiety before

 

Family history

  • Ask if anyone in their close family has had any serious illnesses
  • Ask about family history of disease relevant to the history you’ve taken

 

Drug history

  • Ask if they are taking any regular medications
    • Lots of drugs can cause tiredness/drowsiness
      • Beta-blockers
      • Anti-histamines
      • Anti-depressants eg amitriptyline
  • Ask if they take any over the counter medications
  • Ask if they take any supplements

 

Allergies

  • Ask if they have any allergies
  • Ask what happens

 

Social history

  • Ask about their job, and stress levels
  • Ask about drinking
  • Ask about smoking
  • Ask who they live with and how things are at home

 

Summary

  • Ask the patient if they have any questions or concerns
  • Ask if there is anything they think you haven’t asked
  • Summarise again if relevant
  • Thank the patient for talking to you

 

Next steps

In all cases

FBC, LFTs, U&Es, TFTs, CRP/ESR, suggest improving sleep hygiene

Stress, depression, anxiety

Suggest simple steps to improving sleep hygiene, trying some gentle exercise, referral to online self-help guides, book follow up in about 2 weeks, don’t medicate yet

Diabetes symptoms

Fasting glucose, HbA1c, dietary advice, limb exams to check for neuropathy and vascular exam, fundoscopy

Sleep apnoea

Respiratory exam, referral to sleep apnoea clinic

Organ failure

Relevant exam, BNP, LFTs, U&Es

Hypothyroidism

Thyroid exam, TFTs

IBD

Abdo exam, PR, CRP, p-ANCA, p-ASCA, endoscopy, imaging

RA

Joint exam, rheumatoid factor, anti-CCP, x-ray

 

 

Cancer referrals for fatigue

>40, fatigue, ever smoked

Lung and mesothelioma

2 week CXR

>40, fatigue, asbestos exposure

Mesothelioma

2 week CXR

>40, fatigue + cough OR SOB OR weight loss OR chest pain OR appetite loss

Lung or mesothelioma

2 week CXR

Persistent fatigue in adults

Leukaemia

48h FBC

 

 

Tiredness history taking.docx
Microsoft Word document [17.7 KB]

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