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Probability diagnosis

Stress and anxiety

Inappropriate lifestyle and psychosocial factors


Viral/postviral infection

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

Serious disorders not to be missed


  • cardiac arrhythmia

  • cardiomyopathy

  • incipient CCF


  • hidden abscess


  • hepatitis B and C/others



  • anaemia

  • haemochromatosis

Pitfalls (often missed)

‘Masked’ depression

Food intolerance

Coeliac disease

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


Lack of fitness

Drugs: alcohol, prescribed, withdrawal

Menopause syndrome


Neurological disorders:

  • post-head-injury

  • CVA

  • Parkinson disease

Kidney failure

Metabolic (e.g. hypokalaemia, hypomagnesaemia)

Chemical exposure (e.g. occupational)


  • hyperparathyroidism

  • Addison disease

  • Cushing syndrome

  • narcolepsy

  • multiple sclerosis

  • autoimmune disorders

Masquerades checklist



Drugs (many)


Thyroid disease, other endocrine (as above)

Spinal dysfunction


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


  • 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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