11/13/24, 8\:13 PM Guide | Tiredness history

Tiredness history

Table of contents

Background

Tiredness is a common presenting complaint. Clinicians often use the term 'tired all the time' (shortened to TATT) in medical
notes.
A wide range of conditions can cause tiredness. A thorough history is essential to help guide appropriate investigations and
management.
A patient may complain of feeling tired when they are describing one of three groups of symptoms\:
Daytime somnolence (sleepiness)\: feeling they need to sleep during the day and/or falling asleep at inappropriate or
inconvenient times
Fatigue\: de
these activities"
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A sensation of generalised weakness of the body and/or limbs (less common)
Some patients may have a combination of these symptoms, but determining the predominant feature will help determine the
underlying cause.

Daytime somnolence

Excessive somnolence most commonly results from insu
primary sleep disorder or secondary to a wide range of other conditions.
Primary sleep disorders
Primary sleep disorders include\:
Insomnia
Obstructive sleep apnoea\: airway obstruction during sleep causes excessive snoring and apnoea, resulting in brief arousals
from sleep, which can happen hundreds of times per night. The patient is usually unaware of waking up, but they report
feeling unrefreshed in the morning and may wake with a headache. Bed partners are likely to be able to give a better history
of snoring and apnoeic episodes than the patient.
Restless leg syndrome\: unpleasant feelings in the legs in the evenings and during the night, which improve when the legs
are moved.
Parasomnias\: sleepwalking and night terrors
Other conditions
Other conditions and circumstances associated with poor sleep include\:
Lifestyle factors\: excessive ca
consumption results in poor quality sleep, although patients may perceive that it helps them to initiate sleep. Shift work can
disrupt the circadian rhythm.
Pain (any cause)\: in
and sti
Lower urinary tract symptoms (LUTS)\: prostatic hyperplasia may result in nocturia multiple times per night.
Parkinson’s disease\: daytime somnolence may be due to the disease itself, disturbed sleep at night and/or medications
used in its treatment, such as dopamine agonists.
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Mental health problems\: any condition that causes anxiety or stress may result in sleep problems, particularly di
initiating sleep. In depression, patients often wake early in the morning and cannot get back to sleep.
Medications\: many medications cause somnolence. Some, such as Z-drugs, benzodiazepines and certain antidepressants,
are prescribed to help with sleep but can leave the patient feeling somnolent the following day. Other medications, such as
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opioids and
Narcolepsy
Although less common, it is important to consider narcolepsy in the di
experience a sudden onset of sleep, which they cannot prevent and which can occur when they are active (e.g. during a
conversation). This distinguishes it from normal dozing, which typically occurs during passive activities, such as watching
television.
Additional features of narcolepsy are cataplexy (sudden loss of muscle tone in response to triggers such as laughter and
surprise), hypnagogic hallucinations (distressing hallucinations when falling asleep and/or waking up) and sleep
paralysis.
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Fatigue

The di
presenting symptoms.
Cardiovascular\: heart failure, ischaemic heart disease
Respiratory\: any condition which causes chronic shortness of breath, including chronic obstructive pulmonary disease
(COPD), pulmonary and sarcoidosis
Gastroenterological\: incoeliac disease, autoimmune liver disorders (e.g. primary biliary cirrhosis)
Genitourinary\: uraemia secondary to renal impairment of any cause
Gynaecological\: pregnancy, anaemia secondary to heavy menstrual bleeding of any cause, peri-menopause or menopause
Rheumatological\: systemic lupus erythematosus (SLE), inrheumatoid arthritis), chronic pain
conditions (e.g.
Neurological\: brain tumours, multiple sclerosis, Parkinson’s disease
Haematological\: anaemia of any cause, as well as iron de
Endocrine\: diabetes, hypothyroidism, Addison’s disease
Infective\: fatigue is a feature of many acute infections; it has a particular association with glandular fever, Lyme disease,
acute hepatitis, HIV and tuberculosis (TB). It is also important to consider long-COVID.
Malignancy\: any form of malignancy can cause fatigue, but particularly those which may present with anaemia (e.g.
gastroenterological or haematological malignancies) and those which may be associated with hypercalcemia (e.g. lung,
breast, renal and thyroid cancers)
Medications\: many drugs have a side e
Psychological\: depression and anxiety often cause fatigue, as can acute stress reactions. However, it is also important to
note that fatigue can cause anxiety and depression, meaning that a psychological cause should not be diagnosed without
carefully considering potential physical causes.
Lifestyle/environmental\: excessive exercise, alcohol misuse. Carbon monoxide poisoning should also be considered.
Long COVID
Long COVID (also called post-COVID syndrome) is an emerging condition.
NICE deCOVID-19,
continue for more than 12 weeks, and are not explained by an alternative diagnosis"
4
. Patients may experience other
symptoms besides fatigue, including cough, chest pain, breathlessness, brain fog, headache, palpitations and arthralgia.
CFS/ME
If other causes have been excluded and the fatigue is persistent, chronic fatigue syndrome (CFS) (also known as myalgic
encephalomyelitis or ME) should be considered.
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CFS/ME is de
usual activities, cannot be explained by any other condition and has all of the following\:
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Debilitating fatigue not caused by excessive physical or cognitive exertion and not signi
Post-exertional malaise, which is disproportionate to the activity
Unrefreshing sleep and/or sleep disturbance
Cognitive problems\: word-

Weakness

If weakness is the predominant symptom, consider\:
Neuromuscular disorders, such as motor neurone disease (MND) and myasthenia gravis
Osteomalacia secondary to vitamin D de
Cushing’s syndrome, which causes proximal muscle weakness

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?”
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“ C a n y o u d e s c r i b e w h a t t h a t t i r e d n e s s i s l i k e ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

The
combination\:
" W h e n y o u d e s c r i b e f e e l i n g t i r e d , a r e y o u r e f e r r i n g t o f e e l i n g u n u s u a l l y o r e x c e s s i v e l y s l e e p y ? O r i s i t e x h a u s t i o n o r
w e a k n e s s , b u t w i t h o u t s l e e p i n e s s ?"
Further questions can help clarify which symptom the patient is experiencing.

Onset

Clarify the onset of the tiredness\:
" H o w l o n g h a v e y o u b e e n f e e l i n g t i r e d ?"
" D i d i t c o m e o n s u d d e n l y , o r h a s i t c o m e o n g r a d u a l l y ?"
Sudden onset may point to an acute cause, such as an infection or a new medication.
Gradual onset is more likely seen in chronic conditions such as hypothyroidism, heart failure, liver disease or renal failure.

Associated symptoms

Ask if there are other symptoms which are associated with the tiredness\:
“ A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e t i r e d n e s s ?”
Given the wide di
It may be helpful to group them as follows\:
Cardiovascular or respiratory\: chest pain, shortness of breath, leg oedema, cough
Gastroenterological\: change in bowel habit, nausea or vomiting, abdominal pain, blood loss (fresh rectal bleeding, melaena,
haematemesis)
Genitourinary\: nocturia, polyuria or oliguria, haematuria
Gynaecological\: menorrhagia; menstrual irregularities, including amenorrhea
Rheumatological\: joint or back pain; joint erythema or swelling, rashes
Neurological\: headaches, vomiting, visual disturbances, sensory disturbances, limb weakness, cognitive impairment,
tremors
Haematological\: anaemia may cause breathlessness; the patient or family may have noted unusual pallor.
Endocrine\: polyuria and/or polydipsia, unexplained weight changes, skin changes, symptoms of postural hypotension (seen
in Addison's disease)
Infective\: fevers, night sweats, weight loss, lymphadenopathy
Malignancy\: general symptoms, such as night sweats, weight loss, lymphadenopathy, as well as site-speci
Psychological\: it may be helpful to use the screening questions for depression (see below)
Screening questions for depression
" D u r i n g t h e p a s t m o n t h , h a v e y o u o f t e n b e e n b o t h e r e d b y f e e l i n g d o w n , d e p r e s s e d o r h o p e l e s s ?"
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" D u r i n g t h e l a s t m o n t h , h a v e y o u o f t e n b e e n b o t h e r e d b y l i t t l e i n t e r e s t o r p l e a s u r e i n d o i n g t h i n gs ?"
If the answer to either of these is yes, explore the possibility of depression.

Timing

Clarify how the tiredness has changed over time\:
“ H o w h a s t h e t i r e d n e s s c h a n g e d o v e r t i m e ?”
" I s i t c o n s t a n t , o r d o e s i t g e t b e t t e r a n d w o r s e ?"
Tiredness caused by conditions such as renal failure, heart failure and anaemia will tend to be constant and progressively
worsen over weeks to months.
The tiredness associated with depression is more likely to
CFS/ME are often associated with post-exertional malaise.
It is also helpful to ask if a temporal relationship exists between tiredness and the patient starting new medications.

Daytime somnolence

Additional considerations for patients presenting with daytime somnolence include\:
What happens when the patient feels sleepy? Can they resist sleepiness, or do they fall asleep involuntarily? If they fall
asleep involuntarily, in what sorts of situations would this happen?
Ask the patient to describe their bedtime routine. It is helpful to establish what time they go to bed, sleep latency (how long
it takes them to fall asleep) and at what time they wake up, as well as to
sleep.
The Epworth Sleepiness Scale is a helpful tool to assess the severity of the patient’s sleepiness.
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Red
Red
7
Weight loss of 5% or more over 6-12 months (malignancy, diabetes, Addison’s disease)
Fever, night sweats, lymphadenopathy (malignancy, infection)
Muscle or joint pain (in
Focal neurological symptoms suggesting brain tumour or neurodegenerative disorder
History of tick bites may suggest Lyme disease
Spontaneous onset of sleep when the patient is active, such as when talking or eating (narcolepsy)

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
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Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding which symptoms to ask about depends on the presenting complaint and your experience level. Tiredness has
a broad di
are listed above in the history of presenting complaint section.

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery (e.g. coronary artery bypass grafts, coronary artery stents, heart valve
replacements)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
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Examples of relevant medical conditions
Medical conditions of particular relevance to tiredness include\:
Ischaemic heart disease
Heart failure
Respiratory disease, particularly COPD
Chronic kidney disease
Autoimmune or in
Haematological disorders
Endocrine conditions, such as diabetes and thyroid dysfunction
Malignancy
Infectious diseases
Psychiatric conditions

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
anaphylaxis).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k t h a t y o u r t i r e d n e s s s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
Medication examples
Medications which commonly cause fatigue and/or excessive somnolence include\:
Beta-blockers
Opioids
Hypnotics, such as Z-drugs and benzodiazepines
Anti-depressants, particularly trazodone and mirtazapine
Triptans
First-generation antihistamines, such as chlorphenamine (Piriton)

Family history

Ask the patient if there is any family history of diseases which may be associated with tiredness (e.g.cardiovascular disease,
autoimmune diseases, renal or liver impairment, neurological disorders, endocrine disorders, or malignancy)\:
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
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If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?”

Social history

General social context
Explore the patient’s general social context, including\:
The impact of tiredness on the patient’s ability to function, including their ability to work and to ful
responsibilities.
work)
Life circumstances which may be causing particular stress (e.g. illness in the family, relationship di
Work patterns, in particular, whether the patient regularly works night shifts.
Does anyone who lives in the same property as the patient have similar symptoms? If carbon monoxide poisoning is the
cause, this would be likely to a
Ask about foreign travel, as this may raise the possibility of infectious disease.
Ask about the risk of tick bites from working or walking on land grazed by livestock, or in woodland.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Excess use of alcohol can cause a depressed mood and a reduction in sleep quality, both of which can cause tiredness.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Occupation
Ask about the patient’s current occupation\:
Explore what tasks the patient performs to identify risks posed by fatigue and sleepiness (e.g. operating heavy machinery).
They may need to take a break from work until the problem has been investigated and treated.
Driving
If the patient drives and has presented with daytime somnolence, it is important to advise them not to drive until they have
been fully investigated. They must inform the Driver and Vehicle Licensing Agency (DVLA) if they are diagnosed with a
condition such as obstructive sleep apnoea or narcolepsy.
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Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

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1. NICE CKS. T i r e d n e s s / f a t i g u e i n a d u l t s . Available from\: [LINK]
2. NICE CKS. P a r k i n s o n’ s D i s e a s e . Available from\: [LINK]
t h
3. Boon, NA. Colledge, NR, Walker, BR (eds). D a v i d s o n’ s P r i n c i p l e s & P r a c t i c e o f M e d i c i n e 2 0 E d . Churchill Livingstone Elsevier,
2006
4. BMJ Best Practice. C o r o n a v i r u s D i s e a s e 2 0 1 9 ( C O V I D-1 9 ) Available from\: [LINK]
5. NICE CKS. T i r e d n e s s / f a t i g u e i n a d u l t s . Available from\: [LINK]
6. Epworth Sleepiness Scale. Available from\: [LINK]
7. NICE CKS. T i r e d n e s s / f a t i g u e i n a d u l t s . Available from\: [LINK]
8. DVLA. A s s e s s i n g LINK]
Source\: geekymedics.com
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