TIREDNESS

Conditions and management

By

DR. MO SOBHY

1
 INDEX

1. Overview of tiredness structure………….………. 3

2. Iron deficiency anaemia….……………………………. 5
3. Obstructive sleep apnea………………..…………….. 8
4. Vitamin B12 deficiency…..……………………….……. 11
5. Chronic fatigue syndrome………………………...….. 14
6. Fibromyalgia…………………….………………………… 18
7. Tiredness due to drugs….………………………..……. 21
8. Other tiredness scenarios……………………………..23

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 Differential diagnosis of tiredness

ABCDEF MO
Anaemia
A
 shortness of breath
 noticeable heartbeats
( iron – B12)  pale skin

 while you sleep .making

gasping, snorting or choking
Apnea noises ,waking up a lot and loud
snoring.
 During the day, you may also:
find it hard to concentrate , have
mood swings and have a
headache when you wake up
T.B 

B
a persistent cough with bloody
phlegm.
 weight loss
 night sweats
 high temperature
Cancer 

C
FLAWS
( fever – loss of weight – loss of
appetite – lumps )
 extreme physical and mental
tiredness (fatigue) that does
not go away with rest or sleep.
Chronic fatigue This can make it difficult to
syndrome carry out everyday tasks and
activities.
Drugs 

D
Citalopram
 Steroids

D.M  feeling very thirsty

 peeing more frequently than
usual, particularly at night.
Diet  Vegetarian ( vit B12 – iron ).

Endocrine 

E
Bowel ( constipation)
 Mood ( feeling low )
(hypothyroidism)  Weight gain
 Weather preference (cold)

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 Fibromyalgia
F
 muscle stiffness
 difficulty sleeping
 problems with memory and
concentration
 headaches

Mood
MO
 Exclude Depression

 Always ask about psycho-social impact

- sound quiet distressing
- How is it affecting your life?
- How is it affecting your daily activities?
- What do you do for living ?
- How is it affecting your job?
- How do you feel moodwise ? (must)
- Do you drive? If yes advice not to drive & inform DVLA

 Investigations for all tiredness causes

- FBC : anemia
- FBS/RBS : DM
- LFT : liver failure
- KFT : kidney failure
- TFT : Hypothyroidism
- Urea&electrolytes : Hyponatremia (Citalopram/ steroids)
- Cholesterol : Bad diet
- Vitamens : Vit D, B12
- Infection markers

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 IRON DEFICIENCY ANAEMIA

- Station
You are an FY2 in the GP clinic. Mr. Russell , 45 year old has come
to the clinic today to receive his test results.
He had a blood test done three weeks ago which showed:
Hb: 10 g/dl (11-15) TLC: 4000/cmm Plt: 430,000 MCV: 78 (80-100).
He had blood tests done one week ago as well which show:
Hb: 10.2 g/dl (11-15) TLC : 4300/cmm Plt: 400,000 U&E: Normal
LFTs: Normal Serum Iron: Low Serum Ferritin: Low
MCV: 78 (80-100) Test for celiac disease: Negative. Discuss these test.

Management of iron deficiency anaemia

- Refer to gut specialist to do further tests to find out the reasons for
the anemia. Bleeding in the stomach and intestines is the most common
cause of iron deficiency anaemia. Bleeding may due to many reasons
such as: stomach ulcers or inflammation of the bowel or food pipe.
- Senior
- Life style
 There are things you can do yourself.
 Your diet is partly causing your iron deficiency anaemia, I
would like to tell you what foods are rich in iron so you can eat
more of them.

 Eat and drink more:

 dark-green leafy vegetables like watercress and curly kale

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  cereals and bread with extra iron in them (fortified)
 meat
 dried fruit like apricots, prunes and raisins
 pulses (beans, peas and lentils)

 Eat and drink less:

 tea
 coffee
 milk and dairy
 foods with high levels of phytic acid, such as wholegrain
cereals, which can stop your body absorbing iron from other
foods and pills
 Large amounts of these foods and drinks make it harder for
your body to absorb iron.
 Stop taking unnecessary painkillers without consultation.

- Symptomatic
 you'll be prescribed iron tablets to replace the iron that's missing
from your body.
 The prescribed tablets are stronger than the supplements you can
buy in pharmacies and supermarkets.
 You’ll need to take them for about 6 months.
 Drinking orange juice after you've taken a tablet may help your
body absorb the iron.
 Some people get side effects when taking iron tablets like:
constipation or diarrhea - tummy pain – heartburn - feeling sick -
black poo.
 Try taking the tablets with or soon after food to reduce the chance
of side effects.

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  It's important to keep taking the tablets, even if you get side
effects.
- Specialist
You might be referred to a specialist dietitian if you're finding it hard
to include iron in your diet.

- Follow up
We may carry out repeat blood tests over the next few months to
check that your iron level is getting back to normal.

- Safety netting
 FLAWS
 Bleeding anywhere in your body.
 Keep iron supplement tablets out of the reach of children. An
overdose of iron in a young child can be fatal.

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 Obstructive sleep apnea

- Station
 You are an FY2 in GP Clinic. Mr. Ethan Cruise , 50 years old male,
has come to the clinic today with tiredness for the past 2 months.
He has been diabetic for 10 years. Talk to him, take a history and
discuss appropriate management with him.
Or
 You are an FY2 in GP Clinic. Mr. Brown, 45 years old male, has
come to the clinic today with a sleeping problem for the past 2
months.
Talk to him, take a history and discuss appropriate management
with him

Management of sleep obstructive apnea

- Refer you to a specialist sleep clinic for tests.

- Senior.
- Investigations
 At the clinic , you may be given devices that check things like
your breathing and heartbeat while you sleep.
 You'll be asked to wear these overnight so doctors can check
for signs of sleep apnoea. You can usually do this at home may
need to stay in the clinic overnight.
 The test can show if you have sleep apnoea and how severe it is.
This is based on how often your breathing stops while you sleep.
 Other investigations: routine blood – cholesterol – Blood suger.

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- Symptomatic
Sleep apnoea does not always need to be treated if it's mild.
 You may need to use a device called a CPAP machine.
 It gently pumps air into a mask you wear over your mouth or
nose while you sleep.
 It can help improve your breathing while you sleep, improve the
quality of your sleep and help you feel less tired.
 Using a CPAP machine may feel strange or awkward at first, but
try to keep using it. It works best if you use it every night. Inform
us if you find it uncomfortable or hard to use.
Less common treatments for sleep apnoea are available but may not
work as well as a CPAP machine.

- Lifestyle
There are things you can do to help with sleep apnoea
 These may be all you need to do if your sleep apnoea is mild.
 try to lose weight
 sleep on your side – try taping a tennis ball to the back of
your sleepwear, or buy a special pillow or bed wedge to help
keep you on your side.
 Please avoid
 Smoking
 drinking too much alcohol – especially shortly before going
to sleep
 taking sleeping pills unless recommended by a doctor – they
can make sleep apnoea worse.

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- Safety netting
 You may need to tell the DVLA about your sleep apnoea. Sometimes
you may need to stop driving until your symptoms are under
control.
 If you have headache , weakness in any part in your body come
to us immediately as sleep apnoea can lead to other medical
conditions as high blood pressure and stroke if not treated.

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 Vitamin B12 deficiency anaemia

- Station
You are an FY2 in GP Clinic. Mrs. Olivia Stone , 30 years old, presented a
week ago to the clinic with a history of tiredness for the past 2 months.
She has come to the clinic today to receive her test results done one
week ago which show:
Hb: 10.2 g/dl (11-15) TLC : 4300/cmm Plt: 400,000 U&E: Normal
LFTs: Normal Serum Iron: Normal Serum Ferritin: Normal
MCV: 120 (80-100) Vitamin B12: Low. Discuss these test.

Management of vitamin B12 deficiency anaemia

- You may be referred to a specialist for further tests or treatment.

 A specialist in conditions that affect the digestive system

(a gastroenterologist) – to exclude conditions which make your
digestive system is not absorbing vitamin B12 properly (pernicious
anaemia ) which is not related to your diet.

 A specialist in nutrition (a dietitian) – as a vitamin B12 deficiency

caused by a poor diet and to devise a personalised eating plan for
you to increase the amount of vitamin B12 in your diet.

- Senior.

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- Symptomatic
Vitamin B12 deficiency anaemia is usually treated with injections
of vitamin B12.
 At first , you'll have these injections every other day for 2 weeks
or until your symptoms have started improving.
 After this initial period, your treatment will depend on whether the
cause of your vitamin B12 deficiency is related to your diet or
whether the deficiency is causing any neurological problems, such
as problems with thinking, memory and behaviour.

- If your vitamin B12 deficiency anaemia is diet-related ( as vegan or

vegetarian )
 you may need vitamin B12 tablets for life. You may be advised to
stop taking the tablets once their vitamin B12 levels have returned
to normal and their diet has improved.
 Good sources of vitamin B12 include:
( meat - salmon and cod - milk and other dairy products – eggs )
 You can look for alternatives to meat and dairy products, there
are other foods that contain vitamin B12, such as yeast extract
(including Marmite), as well as some fortified breakfast cereals and
soy products. Check the nutrition labels while food shopping to see
how much vitamin B12 different foods contain.

- If your vitamin B12 deficiency anaemia is not diet-related , You'll

usually need to have an injection of vitamin B12 every 2 to 3 months
for the rest of your life.

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- Safety netting
 If you have neurological symptoms that affect your nervous
system, such as numbness or tingling in your hands and feet, caused
by a vitamin B12 deficiency, come to us as you'll be referred to a
haematologist ( blood specialist ) and may need to have injections
every 2 months.

- Follow up
 To ensure your treatment is working, we may need to do
further blood tests 10 to 14 days after starting treatment to
assess whether treatment is working.
 Another blood test may also be carried out after approximately 8
weeks to confirm your treatment has been successful.
 you may have to return for an annual blood test to see whether
your condition has returned.

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 Chronic fatigue syndrome

- Station
You are the FY 2 in the GP clinic. Mrs Julia Androsen , 35 year old
presented to the GP surgery 6 weeks ago with tiredness. She has come
for follow up. IT has crashed and his records are not available. Take a
history from him and talk to him about the further management.

Management of Chronic fatigue syndrome

- Senior
- Investigations
 Blood ( all tests for tiredness )and urine tests.
 To rule out other conditions that could be causing your symptoms.

- Life style changes

 Diet
 It's important you eat regularly and have a healthy,
balanced diet.
 If you feel sick (nauseous), eating little and often, may
help. If this does not work, medicine can be prescribed.
 Diets that exclude certain food types are not
recommended.
 Sleep, rest and relaxation
 You may have sleep problems as (unrefreshing or
restless sleep or excessive amount of sleep ) that make
your CFS symptoms worse.

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  You should be given advice about how to establish a
normal sleeping pattern.
 limiting rest period during the day to 30 minutes could
help.
 Relaxation techniques, such as breathing exercises.

- Symptomatic
 Treatments for CFS aim to help relieve your symptoms.
 Your treatment will be tailored to your symptoms.
 CFS can last a long time, but most people's symptoms will
improve with time.
 We should discuss all of the options with you, and explain
the benefits and risks of any treatment taking into account
your circumstances and preferences.

 Medicine can be used to relieve some of the symptoms.

 Over-the-counter painkillers can help ease headaches,
as well as muscle and joint pain.
 You may be referred to a pain management clinic if you
have long-term pain.
 Antidepressants can be useful for pain or having trouble
sleeping.
 Amitriptyline may be prescribed to help ease muscle
pain.

- Specialist treatments
There are a number of specialist treatments for CFS.
1. Cognitive behavioural therapy (CBT)
 For mild or moderate CFS.

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  CBT is a talking treatment that can help you manage CFS by
changing the way you think and behave.
 It can help you to: accept your diagnosis - feel more in control of
your symptoms.
 Using CBT does not mean CFS is considered to be a psychological
condition. It's used to treat a variety of long-term conditions.

2. Graded exercise therapy (GET)

 It is a structured exercise programme that aims to gradually
increase how long you can carry out a physical activity.
 It usually involves exercise that raises your heart rate, such as
swimming or walking. Your exercise programme will be
adapted to your physical capabilities.
 GET should only be carried out with the help of a trained
specialist with experience of treating CFS.

3. Activity management
 It involves setting individual goals and gradually increasing
your activity levels.
 You may be asked to keep a diary of your current activity and
rest periods to establish your baseline. Activities can then be
gradually increased in a way you find manageable.

4. Changes in your place of work or study or home could be done.

- Safety netting
 If you have severe CFS and need to spend much of your time in
bed, it can cause problems, including pressure sores and blood
clots. These problems, and how to avoid them, should be
explained to you and your carers.

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  If you feel low due to your symptoms , come to us immediately.

- Follow up
Your treatment plan would be reviewed regularly.

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 Fibromyalgia

- Station
You are the FY 2 in the GP clinic. Mr Tony Peter, 35 year old presented
to the GP surgery 6 weeks ago with tiredness. He has come for follow
up. IT has crashed and his records are not available. Take a history
from him and talk to him about the further management.

Management of Fibromyalgia
- Refer
Different healthcare professionals may also be involved in your care,
such as a:

 Rheumatologist – a specialist in conditions that affect muscles and

joints

 Neurologist – a specialist in conditions of the central nervous

system

 Psychologist – a specialist in mental health and psychological

treatments

- Senior.
- Investigations

 To rule out all other conditions that could be causing your

symptoms as rheumatoid arthritis (a condition that causes pain
and swelling in the joints ) and multiple sclerosis (a condition of
the central nervous system (the brain and spinal cord) that affects
movement and balance ).

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  Tests to check for some of these conditions include urine
and blood tests, although you may also have X-rays and other
scans.

- Symptomatic
You may need to take several different types of medicines for
fibromyalgia.
 Painkillers
If over-the-counter painkillers are not effective, we may
prescribe a stronger painkiller for you..
 Antidepressants can also help relieve pain for some people
with fibromyalgia such as amitriptyline. Antidepressants can
cause a number of side effects, including: sickness – dry mouth –
drowsiness.
 Medication to help you sleep as an over-the-counter remedy,
or we may prescribe a short course of a stronger medication.
 Muscle relaxants If you have muscle stiffness or spasms (when
the muscles contract painfully) as a result of fibromyalgia, we
may prescribe a short course of a muscle relaxant, such as
diazepam.
 Anticonvulsants (anti-seizure) medicine, as these can be
effective for those with fibromyalgia such as pregabalin and
gabapentin. Some common side effects of them include: dizziness
– drowsiness.
 Antipsychotics used to help relieve long-term pain. Possible
side effects include: shaking – drowsiness.
 Treatment of other combined conditions as irritable bowel
syndrome (IBS), you may need to have separate treatment for it.

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- Support group
 Many people also find support groups helpful. Just talking to
someone who knows what you're going though can make you
feel better.
 Fibromyalgia Action UK is a charity that offers information and
support to anyone who has fibromyalgia.

- Specialist treatment
There are other treatment options that can be used to help cope with
the pain of fibromyalgia.
 hydrotherapy or balneotherapy : swimming, sitting or
exercising in a heated pool or warm water.
 an individually tailored exercise programme
 cognitive behavioural therapy (CBT) – a talking therapy that
aims to change the way you think about things, so you can tackle
problems more positively
 psychotherapy – a talking therapy that helps you
understand and deal with your thoughts and feelings
 relaxation techniques
 psychological support – any kind of counselling or support
group that helps you deal with issues caused by fibromyalgia
 Alternative therapies as acupuncture – massage.

- Safety netting
If you feel low , come back to us immediately.

Note

- If the patient has body ache → consider Fibromyalgia as diagnosis.

- If tiredness is more prominent → consider CFS as diagnosis.

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 Tiredness due to drugs

- Station
 An old lady presents with tiredness for 2 months. She is a known
COPD patient. Her GP did blood investigations and referred her
to the hospital. Take a history and carry out management Pt has
COPD for 20 years. Taking Blue and brown inhalers. Blood test
shows low sodium (129 mmol). Talk to her and address her
concerns.
 50 years old female complaining of tiredness you are the FY2 in a
G.P Clinic. Take a history & management.( Citalopram )

Management of hyponatremia due to drugs

- Admit
- Senior
 Causative medications may be stopped.
- Investigations
 Blood tests:
potassium - kidney function - Thyroid function tests – cortisol -
Blood inflammatory markers - random glucose - osmolality
 Urine sample: looking for sodium levels and osmolality which
are useful in determining the cause.
 Imaging: a chest X-ray may be required to exclude heart failure,
or a computerised tomography (CT) brain scan may be necessary
in patients with confusion.
 Other investigations: some other tests which may be undertaken
include a 12-lead heart tracing (electrocardiogram, or ECG), an

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 ultrasound scan of the heart (echocardiogram, or echo) in cardiac
failure and, in kidney disease, a renal ultrasound scan.
- Symptomatic
 Intravenous fluids slowly or fluid restriction in lack of fluid in
the body according to your test results.
 Continous monitoring of your vitals and blood sodium levels.
 Medications for any associated symptoms as headache or
nausea.
 Review medications ( Cialopram - Steroids ) which may have
caused the low blood sodium.

- Specialist
 Refer to Psychiatry after being stable to modify your medications
( Citalopram ).
 Refer to Respiratory after being stable to modify your
medications ( Steroid ).

- Follow up
 clear plan regarding medication and prevention of further
hyponatraemia is required.

- Note
 You should open the BNF and check the medication.

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 Other TIREDNESS scenarios

- Hypothyrodism Station
You are FY2 in GP surgery , 43 years old woman presents with
tiredness. Take a history and discuss management with the patient.
[Positive symptoms - Tiredness, weight gain, constipation, prefers hot
weather]
Will be discussed in endocrine notes.

- Diabetis Station
You are FY2 in GP surgery , 47 years old woman presents with
tiredness. Take a history and discuss management with the patient.
[Positive symptoms – thirsty - polyurea]
Will be discussed in endocrine notes.

- Depression Station
You are FY2 in GP surgery , 33 years old woman presents with
tiredness. Take a history and discuss management with the patient.
[Positive symptoms – low mood – husband death]
Will be discussed in psychiatry notes.

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