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Probability diagnosis

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Stress and anxiety

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Inappropriate lifestyle and psychosocial factors

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Depression

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Viral/postviral infection

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

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Serious disorders not to be missed

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Vascular:

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  • cardiac arrhythmia

  • cardiomyopathy

  • incipient CCF

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Infection:

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  • hidden abscess

  • HIV/AIDS

  • hepatitis B and C/others

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Cancer

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Other:

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  • anaemia

  • haemochromatosis

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Pitfalls (often missed)

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‘Masked’ depression

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Food intolerance

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Coeliac disease

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

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Fibromyalgia

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Lack of fitness

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Drugs: alcohol, prescribed, withdrawal

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Menopause syndrome

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Pregnancy

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Neurological disorders:

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  • post-head-injury

  • CVA

  • Parkinson disease

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Kidney failure

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Metabolic (e.g. hypokalaemia, hypomagnesaemia)

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Chemical exposure (e.g. occupational)

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Rarities:

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  • hyperparathyroidism

  • Addison disease

  • Cushing syndrome

  • narcolepsy

  • multiple sclerosis

  • autoimmune disorders

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Masquerades checklist

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Depression

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Diabetes

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Drugs (many)

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Anaemia

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Thyroid disease, other endocrine (as above)

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Spinal dysfunction

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UTI

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Is the patient trying to tell me something?

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Highly likely.

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Key history

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  • 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

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Key examination

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

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  • Vital signs

  • Anthropometric measurements

  • Basic respiratory and cardiovascular

  • Abdominal examination with focus on masses and inguinal lymphadenopathy

  • Urinalysis

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Key investigations

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  • FBE

  • ESR/CRP

  • Blood sugar

  • Serum electrolytes, calcium, magnesium

  • Kidney function tests

  • Liver function tests

  • Iron studies

  • Faecal occult blood

  • Thyroid function tests

  • CXR

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Diagnostic tips

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  • 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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