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++

Probability diagnosis

++

Stress and anxiety

++

Inappropriate lifestyle and psychosocial factors

++

Depression

++

Viral/postviral infection

++

Sleep-related disorders (e.g. sleep apnoea)

++

Serious disorders not to be missed

++

Vascular:

++

  • cardiac arrhythmia

  • cardiomyopathy

  • incipient CCF

++

Infection:

++

  • hidden abscess

  • HIV/AIDS

  • hepatitis B and C/others

++

Cancer

++

Other:

++

  • anaemia

  • haemochromatosis

++

Pitfalls (often missed)

++

‘Masked’ depression

++

Food intolerance

++

Coeliac disease

++

Chronic infection (e.g. Lyme disease, TB)

++

Fibromyalgia

++

Lack of fitness

++

Drugs: alcohol, prescribed, withdrawal

++

Menopause syndrome

++

Pregnancy

++

Neurological disorders:

++

  • post-head-injury

  • CVA

  • Parkinson disease

++

Kidney failure

++

Metabolic (e.g. hypokalaemia, hypomagnesaemia)

++

Chemical exposure (e.g. occupational)

++

Rarities:

++

  • hyperparathyroidism

  • Addison disease

  • Cushing syndrome

  • narcolepsy

  • multiple sclerosis

  • autoimmune disorders

++

Masquerades checklist

++

Depression

++

Diabetes

++

Drugs (many)

++

Anaemia

++

Thyroid disease, other endocrine (as above)

++

Spinal dysfunction

++

UTI

++

Is the patient trying to tell me something?

++

Highly likely.

++

Key history

++

  • Analysis of presenting complaint including associations

  • General questions covering red flags, weight change, general discomfort, aches or pains, fever, unusual lumps or bumps (lymph nodes), bleeding, rashes or pruritus, sleep patterns including snoring, apnoea

  • Symptoms review especially gastrointestinal, cardiovascular and neurological

  • Drug history including self-medication, OTCs, alcohol, antianxiety, antipsychotics, antidepressants

  • Psychological: stresses, anxiety, depression, sexual problems

  • Social including relationships, abuse or bullying

  • Diet and exercise

++

Key examination

++

General inspection noting facial features, skin appearance and colour, hyperpigmentation, conjunctivae

++

  • Vital signs

  • Anthropometric measurements

  • Basic respiratory and cardiovascular

  • Abdominal examination with focus on masses and inguinal lymphadenopathy

  • Urinalysis

++

Key investigations

++

  • FBE

  • ESR/CRP

  • Blood sugar

  • Serum electrolytes, calcium, magnesium

  • Kidney function tests

  • Liver function tests

  • Iron studies

  • Faecal occult blood

  • Thyroid function tests

  • CXR

++

Diagnostic tips

++

  • Be alert to depression including masked depression.

  • Ask the patient what they believe is the cause of their tiredness.

  • Be alert for the classic endocrine traps: hypothyroidism and Addison disease.

  • Tiredness in absence of red flags is unlikely to have an organic cause.

  • Investigations are likely to be therapeutic and reassuring rather than diagnostic.

  • Learn how to undertake a brief, good physical examination and practise effective time management.

  • Do not overlook a sleep disorder.

  • Believe the patient’s symptoms.

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