1. 🧼 Opening the Consultation

• Wash or sanitise hands
• Introduce yourself: "Hi, my name is (Name), one of the physician associates"
• Confirm the patient's full name and date of birth
• Gain consent: "Would it be okay if I asked you some questions about the tiredness you've been experiencing?"
• Establish whether the patient appears acutely unwell, significantly breathless, confused or unable to manage normal activities

2. ❓ Presenting Complaint

• Begin openly:
  • "What brought you in today?"
  • "Can you tell me more about how you've been feeling?"
• Clarify what the patient means by "tired":
  • "Do you feel physically drained or lacking in energy?"
  • "Do you actually feel sleepy and find yourself falling asleep during the day?"
  • "Do your muscles feel weak or difficult to use?"
  • "Or do you feel breathless when trying to do things?"
• If the patient says…	You should consider…
  "I have no energy even after resting"	True fatigue – explore physical, psychological, sleep-related and systemic causes
  "I keep falling asleep during the day"	Excessive daytime sleepiness – consider obstructive sleep apnoea, medication or sleep deprivation
  "My arms and legs actually feel weak"	True muscle weakness – consider neurological, muscular, endocrine or electrolyte causes
  "I get tired because I can't catch my breath"	Respiratory or cardiovascular cause
  "I'm exhausted after very little activity and feel worse afterwards"	Explore post-exertional malaise and consider ME/CFS or post-viral illness if the wider pattern fits
  "I wake up tired no matter how long I sleep"	Unrefreshing sleep – consider sleep disorder, ME/CFS, mood disorder or another systemic cause

3. 🩺 History of Presenting Complaint

• Onset: "When did you first start feeling unusually tired?"
  Sudden fatigue may follow infection or acute illness. Gradual fatigue is common with anaemia, endocrine disorders, chronic disease, sleep disorders, medication effects and psychological causes.

• Duration: "How long has this been going on for?"
• Pattern: "Is the tiredness there all the time or does it come and go?"
  • Worse in the morning?
  • Worse later in the day?
  • Related to meals?
  • Related to work or shifts?
  • Any completely normal days?
• Progression: "Is it getting better, getting worse or staying about the same?"
  Progressive unexplained fatigue deserves careful assessment, particularly if accompanied by systemic symptoms, bleeding, recurrent infection or functional decline.

• Effect of rest: "Does resting or sleeping make you feel refreshed?"
  Persistent fatigue that is not significantly relieved by rest is an important feature when considering ME/CFS, but other causes must first be assessed.

• Activity: "What happens when you try to exercise or do your usual activities?"
  • Breathlessness?
  • Palpitations?
  • Muscle weakness?
  • Dizziness?
  • Exhaustion afterwards?
• Post-exertional symptoms: "Do you feel significantly worse after physical or mental activity, even if the activity was quite small?"
  Post-exertional malaise may be delayed for hours or days and can cause prolonged worsening of symptoms. This is an important feature of ME/CFS.

• Functional impact: "What are you no longer able to do because of the tiredness?"
  • Work or study
  • Housework
  • Exercise
  • Shopping
  • Personal care
  • Childcare or caring responsibilities
  • Social activities
  Functional decline often gives a better indication of severity than simply asking the patient to rate fatigue from 0 to 10.

• Previous episodes: "Have you experienced this level of tiredness before?"

4. 😴 Sleep History

• Sleep duration: "Roughly how many hours do you sleep each night?"
• Sleep quality: "Do you wake feeling refreshed?"
• Sleep routine:
  • Usual bedtime?
  • Usual waking time?
  • Shift work?
  • Night waking?
  • Difficulty falling asleep?
• Snoring: "Have you been told that you snore loudly?"
• Witnessed apnoeas: "Has anyone noticed that you stop breathing or gasp during your sleep?"
  Snoring, witnessed breathing pauses, choking during sleep, unrefreshing sleep and unexplained daytime tiredness should raise suspicion of obstructive sleep apnoea.

• Other sleep apnoea clues:
  • Morning headaches
  • Nocturia
  • Choking during sleep
  • Fragmented sleep
  • Difficulty concentrating
  • Daytime sleepiness
• Driving: "Do you ever struggle to stay awake while driving?"
  Excessive sleepiness affecting driving or other safety-critical activities requires particular attention.

5. 🩸 Anaemia & Blood Loss Screen

• Ask about:
  • Breathlessness on exertion
  • Palpitations
  • Dizziness
  • Headaches
  • Reduced exercise tolerance
• Bleeding:
  • Heavy menstrual bleeding
  • Rectal bleeding
  • Black stools
  • Blood in urine
  • Recurrent nosebleeds
  • Easy bruising
• Diet: "Do you follow any particular diet or avoid meat or animal products?"
  Iron, vitamin B12 and folate deficiency are potential contributors depending on diet, absorption, medication and blood loss.

6. 🧭 Focused Systems Review

• Endocrine:
  • Weight gain or loss
  • Cold or heat intolerance
  • Constipation or diarrhoea
  • Dry skin or hair changes
  • Palpitations or tremor
  • Menstrual change
  Fatigue combined with weight change, temperature intolerance, bowel changes or menstrual disturbance may suggest thyroid dysfunction.

• Diabetes symptoms:
  • Polyuria
  • Polydipsia
  • Nocturia
  • Unexplained weight loss
  • Recurrent infections
• Cardiovascular:
  • Chest pain
  • Palpitations
  • Exertional breathlessness
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Ankle swelling
  • Syncope or presyncope
• Respiratory:
  • Persistent cough
  • Shortness of breath
  • Wheeze
  • Chest pain
  • Haemoptysis
• Gastrointestinal:
  • Abdominal pain
  • Change in bowel habit
  • Persistent diarrhoea
  • Bloating
  • Reduced appetite
  • Blood in stool
  • Unexplained weight loss
  Consider blood loss, malabsorption and conditions such as coeliac disease when fatigue occurs with gastrointestinal symptoms or nutritional deficiency.

• Renal:
  • Change in urine output
  • Foamy urine
  • Haematuria
  • Peripheral swelling
• Inflammatory or autoimmune:
  • Joint pain or swelling
  • Morning stiffness
  • Rashes
  • Oral ulcers
  • Dry eyes or dry mouth
• Neurological:
  • True muscle weakness
  • Numbness or tingling
  • Balance difficulty
  • Visual disturbance
  • Problems with concentration or memory
• Infection:
  • Fever
  • Night sweats
  • Recent viral illness
  • Persistent or recurrent infection
  • Recent COVID-19 infection
  • Relevant travel or exposure history

7. 🧠 Mood & Mental Wellbeing

• Ask sensitively: "How have things been emotionally recently?"
• Explore:
  • Persistent low mood
  • Loss of interest or enjoyment
  • Anxiety or excessive worry
  • Sleep disturbance
  • Appetite change
  • Poor concentration
  • Loss of motivation
  Fatigue may occur with depression and anxiety, but physical causes should not automatically be attributed to psychological factors.

• If significant low mood is identified: "Have things ever felt so difficult that you've thought about harming yourself or that you would be better off not being here?"

8. 🚩 Fatigue Red Flag Screen

9. 🧠 Recognising Common Fatigue Patterns

10. ⚡ Consider ME/CFS Carefully

• Ask whether there is debilitating fatigue that:
  • Is significantly worse than before the illness
  • Is worsened by activity
  • Is not significantly relieved by rest
  • Has substantially reduced normal activities
• Ask specifically about:
  • Post-exertional malaise
  • Unrefreshing sleep or disturbed sleep
  • Difficulty concentrating or thinking clearly
• NICE recommends suspecting ME/CFS in adults when all four characteristic symptom groups have persisted for at least 6 weeks, significantly reduce previous activity levels and are not explained by another condition.

• Do not diagnose ME/CFS solely because routine blood tests are normal
• Alternative medical explanations should be actively assessed and excluded

11. 📋 Past Medical History

• Previous anaemia or iron deficiency
• Thyroid disease
• Diabetes
• Chronic kidney disease
• Liver disease
• Cardiovascular disease
• Chronic respiratory disease
• Autoimmune or inflammatory disease
• Coeliac disease or malabsorption
• Previous malignancy
• Chronic infection
• Obstructive sleep apnoea
• Depression or anxiety
• ME/CFS
• Previous COVID-19 infection or post-COVID-19 syndrome
• Recent surgery, hospital admission or significant illness

12. 💊 Drug History & Allergies

• "What medications are you currently taking, including anything you've bought yourself?"
• Recent changes: "Has anything recently been started, stopped or had the dose changed?"
• Consider medicines that may contribute to tiredness, including:
  • Sedating antihistamines
  • Opioids
  • Benzodiazepines and sedatives
  • Some antidepressants
  • Some antipsychotics
  • Anticonvulsants
  • Beta-blockers
  • Other medicines with sedating effects
• Ask about supplements, herbal products and recreational substances where relevant
• Allergies: medication + reaction

13. 👨‍👩‍👧‍👦 Family History

• Thyroid disease
• Diabetes
• Anaemia or inherited blood disorders
• Autoimmune disease
• Cardiovascular disease
• Sleep disorders
• Malignancy where relevant

14. 🏠 Social & Lifestyle History

• Occupation:
  • Working hours
  • Shift work or night work
  • Recent increase in workload
  • Physical demands
• Home circumstances:
  • Young children
  • Caring responsibilities
  • Sleep disruption
  • Social support
• Diet:
  • Regular meals
  • Restricted diet
  • Vegetarian or vegan diet
  • Recent appetite change
• Exercise: usual activity level and any recent reduction
• Smoking: current or previous
• Alcohol: amount and frequency
• Recreational drugs
• Caffeine and energy drinks: amount and timing
• Stress: "Have there been any major stresses or changes in your life recently?"
• Menstrual history where relevant:
  • Heavy periods
  • Irregular periods
  • Recent change in menstrual bleeding
• Pregnancy possibility where relevant: "Is there any possibility you could be pregnant?"

15. 💬 ICE – Ideas, Concerns & Expectations

• "Do you have any thoughts about what might be causing the tiredness?"
• "Is there anything in particular you're worried this could be?"
• "What were you hoping we could help you with today?"

16. 🧾 Summarise & Explain Next Steps

"So, you've been experiencing significant tiredness for around (duration). It is (constant/intermittent) and is particularly noticeable (pattern or trigger). Rest (does/does not) improve it, and it has affected your ability to (functional impact). You have also noticed (associated symptoms), with no (important red flags). Relevant background includes (PMH, medication, sleep or social factors)".

"There are several possible causes of tiredness, so I'd like to examine you and use the history and examination findings to decide which investigations would be most useful".

17. 🔬 Investigations - Think Targeted

• There is no single fatigue blood test: investigations should be guided by the history, examination, duration and associated symptoms.
• Full blood count: assess for anaemia and haematological abnormalities.
• Ferritin: consider where iron deficiency or blood loss is possible.
• Thyroid function tests: consider where the overall clinical picture suggests thyroid dysfunction.
• HbA1c or glucose: consider diabetes, particularly with polyuria, polydipsia, recurrent infection or weight change.
• Urea and electrolytes: assess renal function and electrolyte disturbance where appropriate.
• Liver function tests: consider liver disease or systemic illness.
• CRP or ESR: consider where inflammatory, infectious or malignant disease is suspected.
• Vitamin B12 and folate: consider where deficiency is clinically plausible.
• Coeliac screen: consider with iron deficiency, gastrointestinal symptoms, weight loss or otherwise unexplained persistent fatigue.
• Pregnancy test: where pregnancy is possible and clinically relevant.
• Creatine kinase: consider where true muscle weakness, myalgia or muscle disease is suspected.
• 9 am cortisol: consider where symptoms raise suspicion of adrenal insufficiency.
• ECG: consider with palpitations, syncope, chest symptoms or suspected cardiovascular disease.
• Chest X-ray: consider according to respiratory symptoms, examination findings and relevant suspected cancer criteria.
• Sleep assessment: consider further investigation for obstructive sleep apnoea when the sleep history is suggestive.

🎓 Present Back to Examiner (PA Format)

"This is a (age)-year-old (man/woman) presenting with a (duration) history of persistent fatigue described as (description). The symptoms are worse (pattern or trigger), are (relieved/not relieved) by rest and have resulted in (functional impact). Associated symptoms include (relevant positives), with no (important red flags). Sleep history reveals (relevant findings), and relevant background includes (PMH, medication and social factors). My leading differential is (diagnosis), with (diagnosis 2) and (diagnosis 3) also considered. I would perform a focused general and systemic examination and arrange targeted investigations based on the clinical findings".

📚 Key References

• NICE NG206 - Myalgic encephalomyelitis or chronic fatigue syndrome: diagnosis and management.
• NICE NG202 - Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s.
• NICE NG145 - Thyroid disease: assessment and management.
• NICE NG222 - Depression in adults: treatment and management.
• NICE NG12 - Suspected cancer: recognition and referral.