Endocrine Β· Symptom framework

Fatigue & Tiredness

NICE CKS NG12 (2WW) NG206 ME/CFS
FTG
Fatigue & Tiredness Β· Clinical Reasoning Framework v2
GP & SCA Β· NICE CKS 2024 / Multiple Guidelines
~25%GP consultations involve fatigue
Hb <120/130Anaemia threshold (F/M) g/L
TSH >10Treat hypothyroidism (mU/L)
HbA1c β‰₯48Diagnose T2DM (mmol/mol)
β‰₯3 monthsME/CFS minimum duration
PHQ-9Screen depression in all fatigue
2WWCancer referral if red flags
PEMPost-exertional malaise: ME/CFS hallmark
πŸ“‹ Clinical Stem β€” Fatigue & Tiredness Presentation
A patient presents with persistent tiredness or fatigue β€” a symptom requiring systematic exclusion of organic pathology before a biopsychosocial formulation.
"Ms/Mr [Name], 34 years old, presents with a 3-month history of worsening tiredness. They report feeling exhausted from the moment they wake up, struggling to get through the working day, and finding that even light activity leaves them wiped out. Sleep is disturbed β€” they wake frequently and never feel refreshed. They have noticed difficulty concentrating at work and have stopped exercising. They attribute the fatigue to 'stress and overwork' but have come today because it is significantly affecting their quality of life. There is no obvious precipitant, no weight loss, no fever, and no localising symptoms."
Fatigue is a symptom, not a diagnosis β€” the consultation framework must exclude the full differential systematically before attributing to functional or psychosocial causes. The clinical picture shifts dramatically based on associated symptoms, demographics, and examination findings. This stem adapts across anaemia, thyroid disease, depression, ME/CFS, sleep disorder, and malignancy scenarios.
Scenario A β€” Anaemia 28yo woman, 4-month fatigue, heavy periods, pale conjunctivae, palpitations on exertion, Hb 89 g/L, ferritin 4 ΞΌg/L. Wants to know if she needs a transfusion.
Scenario B β€” Hypothyroidism 52yo woman, 6-month fatigue, weight gain, constipation, dry skin, cold intolerance, slowed reflexes. TSH 22 mU/L. Wants reassurance it's "just her age."
Scenario C β€” Depression 41yo man, 5-month fatigue, anhedonia, early morning wakening, poor concentration, reduced libido, has been avoiding friends. PHQ-9 score 17. Thinks he's "just tired."
Scenario D β€” ME/CFS 38yo woman, 18-month profound fatigue, post-exertional malaise after minimal activity, cognitive dysfunction (brain fog), unrefreshing sleep, orthostatic intolerance. All bloods normal. Wants GET referral.
Scenario E β€” Malignancy screen 65yo man, 10-week fatigue, 6 kg weight loss, night sweats, lymphadenopathy on examination. Never smoked. Worried about cancer.
Key variables to adapt for: Age and sex (iron deficiency in women, malignancy in older adults); associated symptoms (weight loss, fever, lymphadenopathy); sleep history (OSA, insomnia); medications (beta-blockers, statins, antidepressants); psychosocial context (life events, carer burden, occupational stress); post-infection context (post-viral fatigue vs. ME/CFS).
Steps:
1
Step 1
History Taking β€” Open Question First Β· Targeted Questions Β· ICE Β· Psychosocial Context
β–²collapse
Fatigue is one of the most diagnostically challenging presentations in primary care β€” it is simultaneously one of the most common symptoms and one of the broadest differentials. The GP's task is to systematically characterise the fatigue (onset, severity, pattern, associated features), screen for the 15+ organic causes that must not be missed, and assess the psychosocial context that is either causal or perpetuating in the majority of cases. Jumping to investigations without a thorough history wastes resources and misses the diagnosis.
πŸŽ“ Consultation opener β€” use existing information first
"I can see from your notes that you've come in today about feeling very tired β€” I'd love to hear about it in your own words. What's been going on?"
The case card will already specify duration and context. Repeating "how long has this been going on?" when it is documented wastes time and loses Global Skills marks. Opening broadly allows the patient to volunteer what they most want to discuss β€” which in fatigue consultations is frequently an emotional agenda (depression, life crisis, fear of cancer) not the symptom itself.
1A β€” Start with an open question: let the patient lead, then move to targeted questions
Question to askWhy it matters clinicallyChanges what?
🟒 OPEN QUESTION β€” always start here"Tell me about this tiredness β€” what's it been like for you?" Allows the patient to lead with the features most significant to them. In fatigue, the narrative often reveals the diagnosis before any targeted questioning β€” grief, relationship breakdown, occupational burnout, or fear of serious illness frequently emerge unprompted.Scores: Global Skills (patient-centredness), Relating to Others (ICE foundation), Tasks (agenda setting). DDxPsychosocialRx plan
Character and onset"Has it come on gradually or suddenly? Were you well before this started?" Sudden onset fatigue after a viral illness suggests post-viral fatigue or ME/CFS. Gradual insidious onset suggests hypothyroidism, anaemia, diabetes, or depression. Sudden onset after a life event points strongly to psychological aetiology.Onset pattern is the single most important discriminating feature in the fatigue history. DDxInv
Severity and functional impact"On a scale of 0–10, how bad is the fatigue? What can't you do now that you could do before?" Quantifying impairment establishes severity and provides a baseline for treatment response. Profound fatigue preventing basic daily activities suggests ME/CFS, severe depression, or malignancy. Mild background tiredness may be lifestyle-related.Functional impact score determines urgency of investigation and referral threshold. DDxReferral
Sleep pattern and quality"Tell me about your sleep β€” how much are you getting? Do you wake up feeling refreshed?" Unrefreshing sleep (waking exhausted despite adequate hours) is a hallmark of ME/CFS. Early morning wakening is a biological marker of severe depression. Loud snoring + daytime somnolence with witnessed apnoeas = obstructive sleep apnoea (STOP-BANG). Excessive sleep need (hypersomnia) may suggest narcolepsy or hypothyroidism.Sleep quality differentiates fatigue aetiologies more than sleep quantity. DDxRx
Post-exertional malaise (PEM)"Does activity β€” even mild activity β€” make the fatigue significantly worse the next day or a few days later?" Post-exertional malaise β€” fatigue worsening >12–48 hours after minimal physical or cognitive exertion β€” is the hallmark and diagnostic criterion of ME/CFS (NICE NG206). It distinguishes ME/CFS from depression and deconditioning where gradual exercise is beneficial.PEM changes management completely: graded exercise therapy (GET) is contraindicated in ME/CFS. DDxRx
Associated symptoms β€” weight change"Have you noticed any change in your weight β€” either loss or gain β€” without trying?" Unexplained weight loss + fatigue = malignancy, hyperthyroidism, diabetes, adrenal insufficiency, or inflammatory bowel disease until proven otherwise β€” always triggers urgent investigation. Weight gain + fatigue = hypothyroidism, depression, or Cushing's syndrome.Weight loss with fatigue is the highest-priority red flag combination in this presentation. Red flagInvReferral
Systemic red flag screen"Have you had any fevers, night sweats, or noticed any lumps anywhere?" B symptoms (fever, night sweats, weight loss) with fatigue = lymphoma until proven otherwise β€” urgent 2WW haematology referral. Lymphadenopathy on history requires examination. Bone pain + fatigue = myeloma or metastatic malignancy.This three-question screen takes 30 seconds and can identify life-threatening pathology. 9992WWInv
Mood and psychological symptoms"How has your mood been? Have you lost interest in things you used to enjoy? Any feelings of hopelessness?" Depression is the most common cause of fatigue in primary care and is consistently missed when not actively screened. PHQ-9 should be used for all patients with fatigue of >4 weeks. Fatigue and low mood have a bidirectional relationship β€” each perpetuates the other.Mandatory in all fatigue consultations regardless of whether the patient raises mood themselves. DDxRxPsychosocial
Thyroid symptom screen"Have you noticed feeling more cold than usual, dry skin, hair loss, constipation, or weight gain?" Hypothyroidism is the second most commonly missed cause of fatigue after depression. Women over 40 are at highest risk. Hyperthyroidism presents with fatigue plus heat intolerance, palpitations, weight loss, and tremor β€” the opposite constellation.A positive thyroid symptom screen mandates TSH regardless of age. DDxInv
Diabetes and metabolic symptoms"Have you been excessively thirsty, passing more urine than usual, or noticed any blurring of vision?" Type 2 diabetes is a common and correctable cause of fatigue. Polyuria, polydipsia, and blurred vision (osmotic symptoms) alongside fatigue mandate HbA1c. Fatigue may be the sole presenting symptom of well-controlled T2DM with suboptimal glycaemia.In patients with obesity, sedentary lifestyle, or family history, diabetes screen should be low threshold. DDxInv
Menstrual and reproductive history (women)"Are your periods regular and how heavy are they? Any chance you could be pregnant?" Heavy menstrual bleeding is the most common cause of iron deficiency anaemia and fatigue in women of reproductive age. Pregnancy causes profound fatigue, especially in the first trimester. Perimenopause is associated with fatigue, sleep disturbance, and mood change.HMB history mandates ferritin; possibility of pregnancy mandates urine hCG before investigation. DDxInvRx
Medication and substance history"Are you taking any medications, supplements, or over-the-counter products? What about alcohol, caffeine, and how much are you sleeping?" Beta-blockers, statins, antihistamines, antidepressants, opioids, and benzodiazepines all cause fatigue as side effects. Alcohol is both a sedative and a disruptor of REM sleep, causing chronic fatigue. Caffeine excess (especially in the afternoon) impairs sleep quality.A medication review may resolve fatigue without any further investigation. DDxRx
1B β€” Red flags: must not miss Β· must ask Β· must act
🚨

Red Flags β€” act before continuing history

Red flagWhy dangerousAction
Unexplained weight loss β‰₯5% body weight + fatigue Malignancy (lung, GI, haematological), severe depression, hyperthyroidism, adrenal insufficiency, or advanced HIV. Weight loss with fatigue is a mandated urgent investigation combination in NICE NG12 (cancer recognition). Urgent bloods + 2WW if indicated
B symptoms: fever + night sweats + weight loss Lymphoma (Hodgkin's or non-Hodgkin's) or other haematological malignancy until proven otherwise. Urgent FBC, LDH, ESR, LFTs, and 2WW haematology referral. Urgent bloods + 2WW haematology
Lymphadenopathy (painless, persistent, generalised) Generalised lymphadenopathy with fatigue raises lymphoma, HIV, EBV, CMV, or SLE. Supraclavicular nodes are particularly ominous (Virchow's node = GI malignancy). Duration >3 weeks mandates investigation. Urgent 2WW + FBC + serology
Suicidal ideation in fatigue + depression Severe depression presenting as fatigue is a common pathway to suicidality. Directly asking about suicidal thoughts is mandatory when PHQ-9 β‰₯10. Never assume the patient will volunteer this without direct inquiry. Same-day mental health assessment
Severe postural dizziness + fatigue + hyperpigmentation Addison's disease (primary adrenal insufficiency) β€” may present as profound fatigue, postural hypotension, hyperpigmentation (buccal mucosa, palmar creases), nausea, and weight loss. Adrenal crisis can be life-threatening if missed. Same-day 9am cortisol + endocrine referral
Fatigue + bone pain + hypercalcaemia symptoms (polyuria, constipation, confusion) Multiple myeloma presents with fatigue, bone pain, recurrent infections, and hypercalcaemia. ESR >100 + anaemia + bone pain = myeloma until excluded. Calcium + protein electrophoresis urgent. Urgent bloods + 2WW haematology
Fatigue + haemoptysis / haematuria / PR bleeding / abnormal bleeding Unexplained bleeding with constitutional fatigue raises haematological malignancy (leukaemia, thrombocytopaenia) or solid organ malignancy. FBC + coagulation + urgent referral to relevant specialist. Urgent FBC + 2WW referral
πŸ›‘οΈ

Safeguarding Considerations β€” Consider in Every Consultation

Fatigue can be a presentation of abuse, neglect, or exploitation. Chronic stress from domestic violence, carer burden, modern slavery, or occupational exploitation presents as medically unexplained fatigue. Consider these causes when no organic pathology is found, particularly when the patient appears fearful, minimises their situation, or has a controlling partner present.
🏠 Domestic Abuse / Coercive Control
  • Chronic stress and hypervigilance from abuse causes profound, persistent fatigue
  • Partner who insists on attending or speaks on behalf of the patient
  • Patient minimises symptoms when partner is present but opens up alone
  • History of repeated presentations with medically unexplained symptoms
  • Fatigue with anxiety, hyperarousal, or sleep disturbance suggesting PTSD
πŸ‘΄ Carer Burnout / Elder Neglect
  • Fatigue in an older patient with a dominant carer β€” consider exploitation or neglect
  • Unpaid carer (younger adult) presenting with exhaustion β€” carer's assessment needed
  • Older patient with unexplained weight loss and fatigue living with relatives β€” neglect screen
  • Patient unable to attend alone; carer answers all questions on their behalf
πŸ§’ Children in the Household
  • Parent with severe depression presenting as fatigue β€” capacity to care for children
  • Child or adolescent presenting with chronic fatigue β€” school attendance, family dynamics
  • Parental alcohol or substance misuse (causing fatigue) with children at home
  • Adolescent with fatigue + school avoidance β€” consider bullying, abuse, eating disorder
⚠ Modern Slavery / Exploitation
  • Patient escorted to appointment, speaks little English, third party translates everything
  • Profound fatigue with physical signs of overwork, poor nutrition, or untreated injury
  • Unable to speak about living or working conditions freely
  • Fearful, avoidant, scripted answers β€” concern about trafficking or labour exploitation
If a safeguarding concern is identified: See the patient alone β€” this is the most important first step. Use your practice's safeguarding policy. For adults: MASH referral if risk of abuse or neglect. For children: safeguarding lead contact immediately. For modern slavery: NHS Duty to Refer pathway. Document reasoning carefully β€” you do not need certainty to refer. DASH risk assessment for domestic abuse.
1C β€” PMH Β· FH Β· Drug history Β· Social history: management impact
🧬 PMH / FH β€” changes management
FactorWhy it mattersManagement impact
Depression / anxiety (previous episodes)Strongest single predictor of fatigue aetiology in primary care; recurrence risk highPHQ-9 immediately; low threshold for antidepressant or NHS Talking Therapies; review previous response
Thyroid disease (previous diagnosis or family history)Hypothyroidism is common, treatable, and frequently recurs; family history doubles riskTSH mandatory; if previously treated, check compliance and current dose adequacy
Autoimmune conditions (RA, SLE, MS, IBD, coeliac)Disease activity causes fatigue independently; anaemia of chronic disease commonDisease-specific review; CRP/ESR; ferritin; consider specialist review if flare
Haematological malignancy (past or family history)Relapse or new primary presents with fatigue; secondary malignancy in treated patientsUrgent FBC; low threshold for 2WW haematology referral
Obstructive sleep apnoea (known or suspected)Untreated or undertreated OSA is a major and correctable cause of daytime fatigueSTOP-BANG screening; review CPAP compliance; refer back to sleep service if inadequate
Chronic kidney diseaseUraemia and renal anaemia cause severe fatigue; often undertreatedU&E + eGFR + FBC; nephrology if eGFR <30 or significant anaemia; erythropoietin consideration
Diabetes (T1 or T2)Poor glycaemic control; hypoglycaemia episodes; neuropathic fatigueHbA1c; review insulin/oral medication; check for complications; refer diabetologist if uncontrolled
Heart failure or ischaemic heart diseaseReduced cardiac output causes exertional fatigue; often attributed to age or depressionBNP; ECG; echocardiogram; cardiology review if decompensated or new-onset HF suspected
πŸ’Š Drug history Β· Social history β€” clinical impact
FactorWhy it mattersManagement impact
Beta-blockers (bisoprolol, atenolol)Fatigue is the most common and dose-dependent side effect; often attributed to the underlying conditionReview dose; consider switching to nebivolol (lower fatigue profile); MDT discussion if cardiac indication
Statins (atorvastatin, simvastatin)Myalgia and fatigue in ~5–10% of users; statin-induced myopathy may cause profound fatigueCK level; trial drug holiday (with cardiologist agreement if high-risk); switch statin or reduce dose
Antidepressants (SSRIs, especially early weeks)Fatigue common in first 2–4 weeks of initiation; may also cause sexual dysfunction and emotional bluntingReview timing of dose; consider switching agent; distinguish drug side effect from disease
Opioids and sedating medicationsDirect cause of daytime somnolence and cognitive fatigue; commonly overlooked in chronic pain patientsReview opioid necessity; attempt deprescribing if appropriate; address underlying pain cause
Alcohol use (AUDIT-C screening)Alcohol disrupts REM sleep, causes nutritional deficiencies (B12, folate, iron), and is a CNS depressantAUDIT-C or CAGE; brief intervention; consider B12/folate supplementation; referral if dependent
Occupational stress / shift work / caring responsibilitiesChronic sleep deprivation from shift work, night shifts, or caring for dependants is a major and underrecognised causeOccupational health referral; social prescribing; carer's assessment if applicable
Recent major life events (bereavement, separation, job loss)Adjustment disorder and grief manifest as profound fatigue, anhedonia, and cognitive slowing β€” mirroring organic diseasePsychological support (IAPT); bereavement counselling; PHQ-9 to distinguish adjustment from depression
Recent viral illness (COVID-19, glandular fever, influenza)Post-viral fatigue is well established; ME/CFS develops in 10% of post-COVID patients; EBV classically causes prolonged fatigue in young adultsMonospot / EBV titres if glandular fever suspected; ME/CFS criteria if PEM present; avoid GET
1D β€” ICE: Ideas Β· Concerns Β· Expectations β€” in every consultation, not just SCA
πŸ’‘ Why ICE matters in Fatigue β€” not a tick-box exercise

Fatigue consultations are uniquely vulnerable to ICE failure. Patients frequently believe they "just need a vitamin injection" or "want their bloods checked," while concealing profound depression, cancer fear, or relationship breakdown. The GP who launches straight into bloods without exploring the patient's model will miss the diagnosis in the majority of cases where fatigue is psychosocial in origin. ICE is the diagnostic tool here, not just a communication nicety.

πŸ’­ Ideas
"What do you think might be causing this tiredness? Have you had any thoughts about what's going on with you?"
Patients with fatigue often have a specific self-diagnosis: "I think I'm anaemic," "I think it's my thyroid," or "I think I'm just stressed." Understanding their model prevents the consultation from becoming a battle β€” and reveals the investigation agenda. Correcting an entrenched wrong belief (e.g. "vitamin deficiency causes tiredness") is easier when you know it exists.
😟 Concerns
"Is there anything about this tiredness that has really worried you β€” something you've been hoping I could rule out?"
Cancer fear is the most common hidden concern in persistent fatigue. Patients frequently postpone attending until they can no longer manage their anxiety about a serious diagnosis. Naming this directly β€” "Some people in your situation worry it might be something like cancer or blood disease β€” is that something on your mind?" β€” unlocks the real agenda and allows targeted reassurance.
🎯 Expectations
"What were you hoping we might be able to do today β€” or what would feel like a useful outcome from this appointment?"
Common expectations in fatigue: comprehensive blood panel, "iron injection," referral to a specialist, or simply a diagnosis after years of being told "everything's normal." Not all are appropriate, but all must be heard. Patients who leave without their expectation addressed will re-attend or seek care elsewhere. Negotiating what can be offered today prevents this.
1E β€” Psychosocial context: the person behind the fatigue
πŸ«‚ Fatigue Is Almost Never Just Physical β€” The Biopsychosocial Web

In the majority of GP fatigue consultations, psychosocial factors are either the primary cause or a major perpetuating factor. Even when organic pathology is identified (e.g. hypothyroidism), psychosocial burden explains why treatment fails to resolve symptoms fully. Addressing the biological cause without the social context leads to repeat consultations and patient frustration. NICE guidelines for ME/CFS (NG206), depression (NG222), and chronic fatigue all mandate biopsychosocial assessment.

πŸ˜” Depression and Anhedonia

Depression is the most common single cause of fatigue in primary care. It commonly presents somatically β€” the patient leads with tiredness, not low mood. PHQ-9 β‰₯10 identifies moderate-severe depression requiring active treatment.

"Have you noticed losing interest or pleasure in things you used to enjoy? How has your mood been underneath all this tiredness?"

If positive: PHQ-9 score; assess suicide risk; NHS Talking Therapies referral or antidepressant; do not treat fatigue in isolation without treating depression.

😰 Anxiety and Chronic Stress

Chronic anxiety activates the HPA axis and maintains high cortisol, disrupting sleep and causing adrenal exhaustion. Burnout β€” defined as chronic workplace stress not resolved by rest β€” presents identically to ME/CFS but has different treatment.

"Would you describe yourself as someone who worries a lot? Has there been significant stress at work or at home that hasn't let up?"

If positive: GAD-7; NHS Talking Therapies referral; occupational health; sleep hygiene; consider buspirone or SSRI if GAD severe.

πŸ’” Grief and Loss

Bereavement causes profound fatigue, anhedonia, and cognitive slowing that closely mimics depression. Complicated grief β€” where grief is disproportionate or prolonged beyond 12 months β€” is associated with severe somatic symptoms including disabling fatigue.

"Have you had any significant losses or bereavements recently β€” or even in the past few years that are still affecting you?"

If positive: normalise grief response; distinguish from clinical depression; bereavement counselling referral (Cruse); PHQ-9 to monitor; NHS Talking Therapies if complicated grief.

πŸ”₯ Occupational Burnout

Burnout is a state of chronic occupational stress characterised by exhaustion, cynicism, and reduced efficacy. It is increasingly recognised in healthcare workers, teachers, carers, and parents. Unlike depression, burnout is context-specific β€” patients feel better outside work.

"How are things at work? Do you ever feel utterly drained by work in a way that doesn't recover over the weekend?"

If positive: occupational health referral; sick note if needed; psychological support; explore options to reduce load; distinguish from ME/CFS (PEM absent in burnout).

πŸ‘Ά Caring Responsibilities and Isolation

Caring for a young child, a person with dementia, or a disabled family member is physically exhausting and socially isolating. Carer fatigue is frequently overlooked β€” the patient presents as the patient, not as the carer.

"Do you have anyone you're caring for at home? What does a typical day look like for you β€” when do you get time for yourself?"

If positive: carer's assessment (social services); carer support groups; respite services; social prescribing referral; NHS Talking Therapies for carer psychological support.

πŸŒ‘ Social Isolation and Meaning

Social isolation and loss of purpose are independent causes of fatigue. Retirement, redundancy, relationship breakdown, or disability-related withdrawal from social life reduce motivational drive and cause a fatigue syndrome physiologically distinct from sleepiness.

"How connected do you feel to people around you? Do you have activities or people that give your day a sense of purpose and structure?"

If positive: social prescribing; community referral (Time to Talk, MIND, leisure centre); volunteer work or structured activity; CBT for low self-efficacy.

πŸŽ“ SCA Checkpoint β€” Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"Tell me about this tiredness β€” what's it been like for you?"
"Is there anything about this fatigue that has really worried you β€” anything you've been hoping I might rule out?"
"How has your mood been underneath all this β€” have you been feeling low or losing interest in things?"
"Have you noticed any weight loss, fever, or night sweats β€” anything like that alongside the tiredness?"
Deductions (examiner flags)
  • Jumping straight to investigation plan without exploring ICE
  • Failing to screen for depression (PHQ-9 not offered or mentioned)
  • Not asking about B symptoms (fever, night sweats, weight loss)
  • Asking about thyroid symptoms without asking about mood β€” investigating without diagnosing
  • Missing PEM question β€” misses ME/CFS and prescribes GET (harmful)
  • No red flag screen for malignancy in a patient over 50 with unexplained fatigue
πŸ”΄ Red β€” failing
No mood screen; no red flag screen; no ICE; launches into investigation plan; misses PEM; does not ask about medications as fatigue cause.
🟠 Amber β€” borderline
Mood screened but PHQ-9 not used; red flags partially covered; ICE partially explored; PEM asked but not interpreted correctly (misses ME/CFS implication); medication review omitted.
🟒 Green β€” passing
Full red flag screen; PHQ-9 offered; PEM specifically asked; ICE fully explored including cancer fear; medication review completed; psychosocial context assessed; fatigue characterised systematically.
2
Step 2
Triage Engine β€” Emergency Β· Urgent Β· Routine
β–²collapse
The vast majority of fatigue presentations are routine. However, a small number require urgent or emergency action β€” and the consequences of missing them are severe. The triage grid below maps the clinical features of fatigue to the appropriate action pathway. Triage is a skill in itself: do not over-investigate every fatigue patient, but do not miss the 1% with life-threatening pathology.
πŸ”΄ Emergency

999 or Same-Day Hospital

Act immediately
  • Adrenal crisis (Addisonian crisis)Profound fatigue + hypotension + vomiting + collapse in known or suspected adrenal insufficiency β†’ IV hydrocortisone emergency
  • Severe anaemia with haemodynamic compromiseHb <70 g/L + chest pain, dyspnoea at rest, tachycardia, or cardiac instability β†’ urgent transfusion assessment
  • Acute suicidal crisis in depression presenting as fatiguePHQ-9 β‰₯20 + active suicidal ideation with intent or plan β†’ same-day mental health crisis team or 136
  • Fatigue + acute cord compression / myelopathyFatigue as presenting complaint of MSCC in known cancer patient β€” any new neurological signs β†’ 999
  • Acute leukaemia presentationProfound fatigue + petechiae/purpura + fever + severe anaemia on FBC (blasts suspected) β†’ urgent haematology same day
🟠 Urgent

Same-Day / 1–2 Week Assessment

Urgent referral / same-day bloods
  • B symptoms (fever + night sweats + weight loss)Lymphoma screen β€” urgent FBC, LDH, ESR, LFTs + 2WW haematology within 2 weeks
  • Unexplained weight loss β‰₯5% + fatigue (age >40)Urgent cancer exclusion β€” same-day bloods; 2WW referral to relevant specialty; CXR
  • Suspected Addison's disease9am cortisol same day; same-day endocrinology if acute features; steroid cover if crisis risk
  • Moderate-severe depression (PHQ-9 β‰₯15) with safeguarding concernSame-day mental health liaison; social services if children at risk; crisis team if suicidal ideation
  • New heart failure suspected (fatigue + orthopnoea + leg swelling)BNP same-day; echo within 2 weeks if BNP elevated; cardiology referral
🟒 Routine

Manage in Primary Care

Systematic investigation + tailored plan
  • Unexplained fatigue >4 weeks, no red flagsFull fatigue blood panel; lifestyle assessment; PHQ-9; review in 2–3 weeks with results
  • Depression-related fatigue (PHQ-9 <15, no risk)Antidepressant + NHS Talking Therapies referral; 2-week review; PHQ-9 monitoring
  • Iron deficiency anaemia (confirmed, haemodynamically stable)Oral iron; investigate cause; FBC recheck at 4–6 weeks
  • Hypothyroidism (confirmed on TSH)Levothyroxine titration; recheck TSH at 6–8 weeks
  • Suspected ME/CFS (PEM + unrefreshing sleep + >3 months)ME/CFS diagnostic workup; specialist referral; energy management (pacing); not GET
πŸŽ“ SCA Checkpoint β€” Step 2TasksGlobal Skills
Triage phrases that score
"There are a few features I want to make sure we pick up on β€” particularly whether there's anything that needs urgent attention alongside the fatigue."
"Given what you've told me, I'm not concerned that this is something that needs emergency attention, but I do want to run some important tests to be thorough."
"I want to make sure we're not missing anything serious before we think about what's most likely causing this."
Triage deductions
  • Sending home a patient with B symptoms without urgent investigation or referral
  • Not assessing suicidal ideation in a patient with PHQ-9 β‰₯15
  • Missing adrenal insufficiency in a patient on long-term steroids with new fatigue
  • Reassuring a patient with unexplained weight loss that "it's probably nothing"
πŸ”΄ Red
Misses B symptoms; fails to assess suicide risk; reassures inappropriately in the face of weight loss; does not arrange urgent investigation for malignancy suspicion.
🟠 Amber
Triage broadly correct but reasoning not explained to the patient; misses one urgent feature; does not clearly communicate what would constitute an emergency requiring earlier review.
🟒 Green
Red flag screen explicit and communicated; urgency matched to clinical features; patient understands which symptoms require immediate vs. routine review; investigation plan proportionate to triage category.
3
Step 3
Do I Need This Examination?
β–²collapse
Examination in fatigue is targeted rather than comprehensive β€” its purpose is to screen for the physical signs of specific diagnoses suggested by the history. A normal examination is itself an important finding that can be used therapeutically to reassure the patient and narrow the differential. Always examine the patient and communicate what you found and what it means β€” this is both good practice and high-scoring SCA behaviour.
ExaminationWhy it mattersWhat finding changes managementChanges management?
General appearance: pallor, jaundice, cachexia Pallor of conjunctivae and palmar creases indicates anaemia. Jaundice + fatigue = hepatic pathology. Cachexia = significant weight loss β€” malignancy, TB, or advanced systemic disease.General observation often gives the diagnosis before any targeted examination. Pallor β†’ FBC urgently; jaundice β†’ LFTs + hepatitis screen; cachexia β†’ urgent cancer workup YES β€” aetiology
Thyroid examination: goitre, consistency, tenderness Enlarged thyroid (diffuse = Graves'/Hashimoto's; nodular = multinodular goitre) with fatigue directs investigation. Tender thyroid suggests subacute thyroiditis causing transient hypo- then hyperthyroidism.Thyroid signs should be elicited whenever thyroid symptom screen is positive. Goitre β†’ TSH + thyroid antibodies + USS thyroid if nodular; tender β†’ CRP + thyroid peroxidase Ab YES β€” investigation pathway
Lymph node examination: cervical, axillary, inguinal, supraclavicular Generalised lymphadenopathy with fatigue = lymphoma, EBV/CMV, HIV, or SLE until proven otherwise. Firm, fixed, non-tender nodes are more suspicious than soft, tender, mobile nodes (reactive).Supraclavicular lymphadenopathy is always sinister β€” mandates urgent workup. Generalised lymphadenopathy β†’ FBC, LDH, ESR, HIV, monospot, 2WW haematology; supraclavicular β†’ 2WW immediately YES β€” urgent if present
Abdominal examination: hepatosplenomegaly, masses Splenomegaly with fatigue = EBV, haematological malignancy (leukaemia, lymphoma), or portal hypertension. Hepatomegaly = hepatic malignancy, fatty liver, hepatitis, or heart failure. Abdominal mass = GI malignancy.Felt splenomegaly has very high positive predictive value for significant haematological disease. Splenomegaly β†’ urgent FBC + monospot + haematology; hepatomegaly β†’ LFTs + USS abdomen; mass β†’ urgent GI 2WW YES β€” urgent referral
Cardiovascular: heart rate, rhythm, BP, JVP, peripheral oedema Tachycardia with fatigue = anaemia, hyperthyroidism, heart failure, arrhythmia. Elevated JVP + peripheral oedema + fatigue = heart failure (decompensated). Orthostatic hypotension + fatigue = Addison's or autonomic dysfunction.Pulse and BP take 60 seconds and can identify life-threatening haemodynamic instability. Tachycardia β†’ ECG + FBC + TSH; JVP raised + oedema β†’ BNP + echo; postural BP drop >20mmHg β†’ cortisol + autonomic screen YES β€” multiple pathways
Mental state examination: affect, concentration, psychomotor retardation Psychomotor retardation (slow speech, slow movement), flat affect, and impaired concentration are objective signs of severe depression. Distinguishing depression from hypothyroidism on examination requires both thyroid examination and MSE.MSE in fatigue is a clinical skill often overlooked β€” performing it demonstrates examiner-level clinical reasoning. Psychomotor retardation β†’ severe depression; administer PHQ-9; urgent psychiatry if severe; initiate antidepressant; assess suicide risk YES β€” management urgency
Skin examination: hyperpigmentation, pallor, petechiae, bruising, rash Hyperpigmentation of buccal mucosa and palmar creases = Addison's disease. Petechiae and easy bruising = thrombocytopaenia (haematological malignancy). Butterfly rash = SLE. Spider naevi + jaundice = hepatic disease.Skin examination takes 2 minutes and can diagnose Addison's, haematological malignancy, or SLE immediately. Hyperpigmentation β†’ 9am cortisol immediately; petechiae β†’ urgent FBC + haematology; butterfly rash β†’ ANA + anti-dsDNA YES β€” diagnosis changes
BMI and waist circumference Obesity is independently associated with fatigue via sleep apnoea, insulin resistance, and inflammatory cytokines. Underweight (BMI <18.5) in a fatigued patient raises eating disorder, malignancy, or severe depression.BMI contextualises the fatigue and identifies metabolic risk factors for multiple aetiologies. High BMI + snoring β†’ STOP-BANG for OSA; low BMI + fatigue β†’ eating disorder screen + malignancy workup YES β€” investigation direction
πŸŽ“ SCA Checkpoint β€” Step 3TasksGlobal Skills
Examination communication that scores
"I'm going to do a brief examination β€” I want to check a few things including your neck for thyroid or lymph nodes, your tummy, and your heart rate."
"Your examination is reassuring β€” your lymph nodes aren't swollen, your thyroid feels normal, and there's no sign of anaemia in your conjunctivae."
"I notice your pulse is a little fast β€” that's something I want to investigate alongside the other tests."
Examination deductions
  • Not examining at all in a fatigue consultation with no prior investigation
  • Performing thyroid examination but forgetting lymph nodes in a patient with B symptoms
  • Missing abdominal examination in a patient with weight loss and fatigue
  • Not communicating examination findings to the patient after completing it
πŸ”΄ Red
No examination performed; misses lymphadenopathy in B symptom patient; does not check for postural hypotension in patient with suspected Addison's.
🟠 Amber
Examination targeted appropriately but findings not communicated; misses one key component (e.g. skin examination); BMI not checked in patient with possible OSA.
🟒 Green
Targeted examination with rationale explained; findings communicated with interpretation; normal findings used therapeutically for reassurance; abnormal findings prompt appropriate urgent action.
4
Step 4
Do I Need This Investigation?
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A structured fatigue blood panel should be sent in any patient with fatigue of >4 weeks without a clear non-organic explanation. The standard panel excludes the most common and treatable organic causes. Do not send an endless cascade of tests β€” it generates incidental findings, delays management, and reinforces illness behaviour. The clinical question for each test is: "If this is abnormal, will I act on it?" If yes, order it. If not, don't.
InvestigationClinical question it answersWhat result changes management?
FBC (Full blood count) Anaemia (low Hb, MCV pattern), leukaemia (very high or very low WBC), thrombocytopaenia, polycythaemia. The most important single investigation in fatigue. Hb <120 (F) / 130 (M) g/L β†’ treat cause + oral iron/B12/folate; WBC abnormal (very low or very high, blasts) β†’ urgent haematology; Plt <50 β†’ urgent haematology
TSH (Thyroid stimulating hormone) Hypothyroidism (raised TSH) and hyperthyroidism (suppressed TSH). TSH is the single best thyroid screening test. If abnormal, follow with free T4 Β± T3. TSH >10 mU/L β†’ start levothyroxine; TSH 4.5–10 + symptoms β†’ treat; TSH <0.1 β†’ hyperthyroidism workup; refer endocrinology if complex
HbA1c Diabetes (β‰₯48 mmol/mol) and pre-diabetes (42–47 mmol/mol). Often the first sign of T2DM in an asymptomatic patient who presents with fatigue. HbA1c β‰₯48 β†’ diabetes management pathway (lifestyle, metformin, referral to diabetes nurse); β‰₯42 β†’ pre-diabetes: intensive lifestyle intervention + 6-monthly review
Ferritin + serum iron + TIBC Iron deficiency (low ferritin) β€” the most common nutritional deficiency causing fatigue, especially in women. Ferritin is the most sensitive marker; serum iron and TIBC characterise the pattern. Ferritin <30 ΞΌg/L β†’ iron deficiency (even if Hb normal β€” tissue iron deficiency causes fatigue); treat cause (HMB, coeliac); oral iron supplementation
CRP + ESR Inflammatory activity (RA, SLE, vasculitis, IBD, temporal arteritis) and infection (occult abscess, osteomyelitis, endocarditis). ESR >100 = myeloma or severe inflammatory disease. CRP >50 without obvious cause β†’ investigate infection/inflammatory/malignant cause; ESR >100 β†’ SPEP + Bence Jones protein + myeloma screen
LFTs (Liver function tests) Hepatic disease (hepatitis B/C, NAFLD, alcoholic liver disease, malignancy). Fatigue is often the presenting symptom of chronic liver disease. Raised GGT suggests alcohol use. Raised bilirubin + raised transaminases β†’ hepatitis screen (HBsAg, HCV Ab); isolated GGT rise β†’ alcohol screen; ALP pattern β†’ bone or liver origin
U&E + eGFR (Renal function) Chronic kidney disease causes fatigue via uraemia and renal anaemia. Hypercalcaemia (raised calcium) causes fatigue, constipation, and confusion β€” raised in myeloma, malignancy, and primary hyperparathyroidism. eGFR <30 β†’ nephrology referral + review medications; calcium >2.6 mmol/L β†’ PTH + 24h urinary calcium + myeloma screen + malignancy workup
Vitamin B12 + folate B12 deficiency (especially in vegans, elderly, metformin users, or those with autoimmune gastritis) causes macrocytic anaemia and neurological fatigue. Folate deficiency causes similar haematological picture. B12 <180 pmol/L β†’ hydroxocobalamin IM injections; investigate for pernicious anaemia (parietal cell Ab, intrinsic factor Ab); folate deficiency β†’ folic acid supplementation + dietary advice
PHQ-9 (Patient Health Questionnaire-9) Validated screening tool for depression severity. PHQ-9 β‰₯10 = moderate-severe depression. Essential in all fatigue presentations β€” depression is the most common aetiology and consistently missed without formal screening. PHQ-9 β‰₯10 β†’ antidepressant Β± NHS Talking Therapies referral; PHQ-9 β‰₯15 β†’ assess suicide risk; PHQ-9 β‰₯20 β†’ urgent psychiatric review; PHQ-9 <10 β†’ NHS Talking Therapies self-referral + review
πŸŽ“ SCA Checkpoint β€” Step 4TasksGlobal Skills
Investigation communication that scores
"I'd like to run some blood tests to check for the most common treatable causes β€” things like anaemia, thyroid function, diabetes, and some markers of inflammation."
"I also want to ask you to fill in a short questionnaire about your mood β€” it's something we use routinely in fatigue because low mood and tiredness are so closely linked."
"If all the blood tests come back normal, that's also useful information β€” it helps us focus on other causes like sleep, stress, or how your body is responding to what's been going on in your life."
Investigation deductions
  • Ordering no investigations in a patient with 3-month unexplained fatigue
  • Ordering TSH but not FBC in a patient with pallor and heavy periods
  • Not using PHQ-9 as a validated tool β€” asking "are you depressed?" is not equivalent
  • Ordering a full autoimmune screen (ANA, ANCA, RF) without clinical indication
πŸ”΄ Red
No investigations ordered; investigation plan does not include FBC or TSH; PHQ-9 not used; orders shotgun investigations without explaining rationale to patient.
🟠 Amber
Standard fatigue panel ordered but not explained; misses ferritin in a woman with heavy periods; mentions PHQ-9 but does not administer or reference it; does not explain what abnormal results would mean.
🟒 Green
Standard fatigue panel justified with explanation; PHQ-9 used; clinical history informs additional investigations (ferritin for women, PSA for men over 50, monospot for young adults after viral illness); patient understands the purpose of each test.
5
Step 5
Reaching a Diagnosis & DDx β€” Explained in Plain Language
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Communicating a fatigue diagnosis requires particular skill. Many patients present having been told "everything is normal" for years β€” they need validation and a positive framework. Others fear cancer and need explicit, targeted reassurance. For complex diagnoses like ME/CFS or burnout, giving a clear, named diagnosis with an evidence-based management plan is transformative β€” patients frequently describe it as the first time they felt believed.
πŸ—£οΈ Explaining the Diagnosis in Plain Language β€” say something like this

"What your blood tests are showing is that your thyroid gland β€” which is like the engine regulator of your body β€” is working more slowly than it should. When that happens, it affects everything: your energy, your mood, your metabolism, and even your thinking. The good news is this is very treatable β€” with a small daily tablet, most people feel significantly better within 6 to 8 weeks. It's one of those diagnoses where treatment really does make a big difference, and I'm glad we caught it." [Adapt this framework for the specific diagnosis β€” anaemia, depression, diabetes, or ME/CFS β€” using a body analogy appropriate to that condition.]

πŸ’¬ Addressing the patient's own explanation β€” why it may not be the full picture

"I just think I'm anaemic β€” can I have an iron injection?"
"I completely understand why you're thinking along those lines β€” and we'll definitely check your iron levels. The reason I don't want to just give an injection without testing first is that iron overload can actually be harmful, and there may be a different type of anaemia that needs a different treatment altogether. Let's get the blood results and then we can discuss exactly what would help most."

"I think I'm just tired because I'm busy β€” I don't think I'm depressed."
"That's a really important distinction, and I want to explore it carefully with you. Busyness and stress can definitely cause tiredness β€” but there's a specific pattern of fatigue that comes with depression, and it often doesn't feel like 'being depressed' in the way people imagine. The questionnaire I'd like you to complete helps me be more precise about which of these is most likely to be driving how you feel."

A β€” Diagnosable and Manageable in Primary Care
GP can diagnose and treat

Iron deficiency anaemia β€” Hb low + ferritin <30 ΞΌg/L; treat cause + oral iron; FBC at 4 weeks.

Hypothyroidism β€” TSH >10 mU/L or elevated with symptoms; levothyroxine; recheck TSH at 6–8 weeks.

Depression β€” PHQ-9 β‰₯10; SSRI + NHS Talking Therapies; 2-week review; PHQ-9 monitoring.

Type 2 diabetes β€” HbA1c β‰₯48 mmol/mol; lifestyle + metformin; diabetes pathway.

B12 / folate deficiency β€” treat and investigate underlying cause (pernicious anaemia, diet).

Medication-related fatigue β€” beta-blockers, statins, sedatives; medication review and dose adjustment.

B β€” Suspected β€” Shared Care / Specialist Input
Initiate in GP, refer for confirmation

ME/CFS (Myalgic Encephalomyelitis / CFS)

PEM + unrefreshing sleep + cognitive dysfunction + >3 months β†’ specialist ME/CFS service referral; pacing (energy management); NOT GET.

Obstructive Sleep Apnoea

STOP-BANG β‰₯3 + daytime somnolence + snoring + witnessed apnoeas β†’ sleep study referral; CPAP if confirmed.

Addison's Disease

9am cortisol + ACTH stimulation test β†’ endocrinology; hydrocortisone replacement; steroid emergency card.

C β€” Emergency / Urgent β€” Act Now
Diagnose & refer immediately

Lymphoma

B symptoms + lymphadenopathy + raised LDH β†’ urgent 2WW haematology; staging CT; PET-CT.

Leukaemia (acute)

Abnormal FBC (high WBC / blast cells / pancytopaenia) + constitutional fatigue β†’ same-day haematology emergency referral.

Multiple Myeloma

Bone pain + fatigue + ESR >100 + hypercalcaemia + SPEP paraprotein β†’ urgent haematology 2WW; skeletal survey.

πŸ“Š Fatigue Differential β€” Key Discriminating Features
DiagnosisDiscriminating featuresKey investigationFirst-line management
Iron deficiency anaemiaWomen of reproductive age; HMB; pallor; pica; Hb low with microcytic indicesFBC + ferritin + reticulocyte countFerrous sulfate 200mg TDS; treat cause; FBC at 4 weeks
HypothyroidismWomen >40; weight gain; cold intolerance; constipation; dry skin; slowed reflexes; raised TSHTSH (Β± free T4 if TSH abnormal)Levothyroxine 50mcg OD (25mcg if elderly/cardiac risk); titrate by TSH
DepressionLow mood + anhedonia + early morning wakening + guilt + suicidal ideation; PHQ-9 β‰₯10; fatigue worse in morningPHQ-9 scoreSSRI (sertraline 50mg OD) + NHS Talking Therapies; 2-week review
Type 2 DiabetesPolyuria, polydipsia, blurred vision; obesity; family history; HbA1c β‰₯48 mmol/molHbA1c (repeat if borderline)Lifestyle + metformin 500mg OD (titrate); diabetes nurse referral
ME/CFSPost-exertional malaise; unrefreshing sleep; cognitive dysfunction; >3 months; normal investigations; worsens with activityExclusion of organic causes (full fatigue panel)Pacing / energy management; specialist ME/CFS referral; NOT graded exercise therapy
Obstructive Sleep ApnoeaObese male; loud snoring; witnessed apnoeas; Epworth >10; non-restorative sleep; morning headacheSTOP-BANG + Epworth β†’ sleep studyCPAP; weight loss; ENT referral if structural cause
LymphomaPainless lymphadenopathy; B symptoms (fever, night sweats, weight loss); raised LDH; raised ESR; age anyFBC + LDH + ESR + 2WW haematologyUrgent 2WW referral; staging CT; haematology management
πŸŽ“ SCA Checkpoint β€” Step 5TasksRelating to OthersGlobal Skills
Diagnostic phrases that score
"Based on what you've told me and what the blood tests show, I think this is [diagnosis] β€” let me explain what that means in practical terms."
"I want to be clear about what I've ruled out β€” I haven't found any signs of [cancer / infection / serious blood disease], and that's very reassuring."
"The diagnosis I'm thinking of β€” ME/CFS β€” is a real, recognised medical condition. It's not 'all in your head,' and I want you to know I take it very seriously."
Diagnostic deductions
  • Saying "all your bloods are normal" without exploring psychosocial causes
  • Using the phrase "medically unexplained" without a positive framework for the patient
  • Telling a patient they have ME/CFS without completing a full exclusion workup
  • Diagnosing depression without using a validated tool (PHQ-9)
πŸ”΄ Red
No diagnosis offered; "all bloods normal" with no further plan; uses jargon without explanation; dismisses patient concern about cancer without addressing it.
🟠 Amber
Correct diagnosis but no plain-language explanation; cancer concern not explicitly addressed; ME/CFS mentioned but patient not told about GET contraindication; depression diagnosed without PHQ-9.
🟒 Green
Named diagnosis in plain language with analogy; cancer excluded explicitly; fatigue validated as real; management plan logically follows diagnosis; patient understands what the diagnosis means for their daily life.
6
Step 6
If Referral Is Needed β€” What the GP Does Before & During
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Most fatigue is managed entirely in primary care. When referral is required, it is typically because the investigation findings indicate a specialist diagnosis, the severity of the condition requires specialist input, or primary care treatment has failed. The GP remains the coordinator of care β€” referral is not handover of responsibility.
Condition / ScenarioUrgencyWhat GP does before referralWhat GP must NOT do
Suspected lymphoma (B symptoms + lymphadenopathy) 2WW haematology Send urgent FBC, LDH, ESR, LFTs, and CXR; inform patient sensitively that urgent investigation is needed to rule out a serious blood condition; complete 2WW referral form with full symptom documentation. Do NOT tell patient it is definitely cancer before diagnosis; do NOT delay referral to repeat bloods; do NOT refer to general medicine instead of haematology for B symptoms.
Acute leukaemia (abnormal FBC with blast concern) Same-day emergency Phone haematology registrar directly; do not wait for clinic appointment; arrange same-day hospital attendance; inform patient calmly that the blood test needs urgent specialist review. Do NOT send routine 2WW; do NOT manage neutropenic sepsis in primary care; do NOT delay for repeat FBC if blasts are reported on blood film.
Suspected Addison's disease Urgent endocrinology within 1 week 9am cortisol same day; if cortisol <170 nmol/L β†’ urgent endocrinology referral; provide steroid sick day rules and emergency steroid card while awaiting review; educate on adrenal crisis signs. Do NOT start hydrocortisone without endocrinology input in non-emergency setting; do NOT leave patient without crisis guidance; do NOT dismiss diagnosis because cortisol is borderline β€” refer for ACTH stimulation test.
ME/CFS (criteria met, normal investigations) Routine β€” ME/CFS specialist service Confirm diagnostic criteria (NICE NG206: PEM + unrefreshing sleep + cognitive dysfunction + β‰₯3 months); explain the diagnosis clearly; begin pacing education; provide written information (ME Association leaflet); fit note if appropriate; refer to local ME/CFS service. Do NOT recommend graded exercise therapy (GET) β€” NICE NG206 explicitly removed GET from ME/CFS treatment; do NOT refer for psychological therapy alone as primary treatment; do NOT tell patient "there's nothing wrong with you."
Obstructive sleep apnoea (STOP-BANG β‰₯3 + Epworth >10) Routine β€” sleep medicine STOP-BANG and Epworth Sleepiness Scale documented; advise patient not to drive if Epworth >15 or if professional driver β€” DVLA notification required; weight loss advice; avoid alcohol; refer sleep clinic for polysomnography. Do NOT allow a professional driver (HGV, bus, pilot) to continue driving with suspected severe OSA without DVLA notification; do NOT start CPAP without diagnostic sleep study confirmation.
Severe depression with safeguarding concerns / suicidal ideation Same-day mental health crisis team Full suicide risk assessment; contact on-call psychiatry or CRHT (Crisis Resolution Home Treatment team) same day; do not leave patient alone in the waiting area; safeguarding referral if children at risk. Do NOT send a patient with active suicidal ideation home without crisis support; do NOT start antidepressant as sole management in severe depression β€” specialist input needed; do NOT underestimate lethality of suicidal ideation in a patient presenting with somatic symptoms.
New heart failure suspected (fatigue + BNP elevated) Rapid access heart failure clinic (2 weeks) BNP or NT-proBNP; ECG; CXR; initiate loop diuretic if fluid overloaded; refer to rapid access HF clinic; educate patient on fluid restriction, daily weighing, and when to seek urgent review. Do NOT delay referral while monitoring β€” NICE NG106: BNP >400 β†’ echocardiogram within 2 weeks; do NOT start ACEi or beta-blocker without confirmed diagnosis and specialist guidance.
πŸŽ“ SCA Checkpoint β€” Step 6TasksRelating to Others
Referral communication that scores
"These blood results have shown something I want to investigate further β€” I'm going to refer you urgently to a specialist who can look into this properly."
"I want to be honest with you β€” these results need specialist input. I don't have all the answers yet, but I'm going to make sure you're seen quickly."
Referral deductions
  • Recommending GET for a patient with confirmed ME/CFS (NICE NG206 explicitly contra-indicated)
  • Routine referral for a patient with B symptoms (must be 2WW)
  • Allowing professional driver with severe OSA to continue driving without DVLA notification
  • Sending a patient home with active suicidal ideation without crisis team involvement
πŸ”΄ Red
Wrong urgency for referral; recommends GET for ME/CFS; fails to crisis-refer patient with suicidal ideation; no DVLA advice for professional driver with OSA.
🟠 Amber
Correct referral pathway but wrong urgency; does not explain referral rationale to patient; omits pre-referral actions (steroid card for Addison's, DVLA for OSA).
🟒 Green
Correct pathway with correct urgency; pre-referral actions completed; patient informed of what to expect; safety-netting given while awaiting referral; sensitive communication about why referral is needed.
7
Step 7
Management β€” Expectation Β· Goals Β· Lifestyle Β· Prescribing Β· Psychosocial Β· Follow-Up Β· Safety-Netting
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Management of fatigue is diagnosis-specific β€” there is no single treatment pathway. The framework below applies to the most common scenario: a patient with no organic pathology yet identified, in whom the fatigue is likely multifactorial (psychosocial + lifestyle + possibly early organic disease). Where a specific organic diagnosis has been established, treatment is directed at the cause. Crucially, the management of ME/CFS follows NICE NG206 (2021) β€” graded exercise therapy is no longer recommended.
7A β€” Address the patient's expectation first: validate β†’ explain β†’ negotiate
🀝
Never dismiss the expectation β€” acknowledge it, share your reasoning, then agree a shared plan
1
Validate β€” name their expectation

Patients with fatigue often feel their symptoms have been dismissed or attributed to "lifestyle" without investigation. Validating both their symptom and their expectation builds the trust needed for the rest of the consultation.

"I can hear how much this tiredness is affecting your life β€” it sounds completely debilitating, and I take that seriously. I understand you were hoping we might be able to get to the bottom of what's causing it today."
2
Explain β€” share your clinical reasoning

Explain the investigation strategy and the range of possible causes. Patients who understand why they are being tested β€” and what the results might mean β€” are more likely to engage with the plan and return with results.

"The reason I want to run some blood tests first is that there are several common and very treatable causes of fatigue β€” thyroid problems, anaemia, blood sugar β€” and I want to know if any of those are driving this before we look at other things."
3
Negotiate β€” offer something today

Even before results are back, there is almost always something useful to offer β€” lifestyle advice, sleep guidance, a PHQ-9 to quantify mood, or a written action plan. Leaving without any intervention feels dismissive.

"While we wait for the results β€” which I'd like you to come back to discuss in two to three weeks β€” I want to give you some things that are likely to help regardless of what comes back. Let's talk about sleep, activity, and how you're feeling emotionally."
Key principle: The patient's expectation often reveals the diagnosis. "I just want an iron injection" may signal a patient who knows her periods are heavy but doesn't want to discuss them. "I want to know I don't have cancer" reveals the hidden agenda. Naming the expectation and the diagnosis it implies is a high-yield SCA behaviour.
7B β€” Why treatment matters: goals tailored to this patient
Treatment goals β€” shared with the patient
Identify and treat the underlying cause Restore functional capacity and quality of life Return to work or normal daily activities Optimise sleep quality and quantity Address depression / anxiety if present Avoid iatrogenic harm (unnecessary tests, over-investigation) Reduce reconsultation through effective self-management Named follow-up with review of results and response to treatment
Motivational language β€” tailored to the patient
"If this turns out to be your thyroid β€” and that's one of the things I'm looking for β€” the great news is that treatment usually makes a very significant difference within 6 to 8 weeks. People often describe feeling like themselves again for the first time in years."
"I know it feels like you've tried everything. What I want to do is take a fresh, systematic look β€” because in my experience, when we approach fatigue this carefully, we almost always find something we can actually do something about."
7C β€” Non-medication management: mechanism + evidence + tailored advice
Lifestyle interventions have strong evidence in fatigue management and should be offered alongside any pharmacological treatment. However, advice must be diagnosis-specific β€” exercise is therapeutic in depression but potentially harmful in ME/CFS (PEM); sleep restriction is indicated in insomnia but counterproductive in depression. Always check for PEM before recommending activity-based interventions.
😴
Sleep Hygiene
7–9 hours; consistent sleep-wake cycle
Mechanism

Irregular sleep-wake cycles disrupt circadian rhythm and melatonin production. Sleep deprivation impairs hypothalamic-pituitary-adrenal axis function and reduces pain threshold, worsening fatigue in all aetiologies.

Practical

Fixed wake time regardless of how poorly slept (strongest evidence); no screens 1 hour before bed; dark, cool, quiet room; avoid napping in the afternoon (unless ME/CFS with PEM β€” pacing overrides this rule); limit caffeine after noon.

Consistent sleep-wake time improves fatigue more than any single medication in insomnia
🚢
Graded Activity (Non-ME/CFS)
150 min/wk moderate; start very low
Mechanism

Regular aerobic exercise increases mitochondrial density, improves insulin sensitivity, elevates endorphins, and improves sleep quality. It is one of the most effective treatments for depression-related fatigue.

Practical

⚠ DO NOT recommend in ME/CFS (PEM risk). For depression/burnout: start with 10-minute daily walks; social exercise (group classes) improves adherence; swimming or cycling if joint pain present.

As effective as SSRIs for mild-moderate depression; adjunct benefit in depression of any severity
⚑
Energy Management (ME/CFS)
Pacing within energy envelope
Mechanism

In ME/CFS, the energy envelope is reduced and overexertion triggers post-exertional malaise (PEM). Pacing β€” staying within the available energy envelope β€” prevents boom-bust cycles that worsen the condition over time.

Practical

Heart rate monitoring (keep HR below anaerobic threshold, often 60–70% maximum); activity diary; planning rest before and after activities; breaking tasks into smaller chunks. NICE NG206 supports pacing as first-line.

Pacing is the NICE-recommended first-line intervention for ME/CFS (NG206, 2021)
🍎
Nutrition and Hydration
Balanced diet; iron-rich foods; B12 sources
Mechanism

Iron, B12, folate, vitamin D, and magnesium deficiencies all impair cellular energy production (mitochondrial function) and neurotransmitter synthesis. Even subclinical deficiency causes fatigue.

Practical

Iron: red meat, dark leafy greens, fortified cereals + vitamin C to improve absorption. B12: meat, fish, eggs, dairy (supplementation for vegans). Hydration: 2 L/day β€” mild dehydration causes significant fatigue. Avoid excessive caffeine and alcohol.

Correcting nutritional deficiencies resolves fatigue in the majority of cases of iron/B12 deficiency
🧠
Stress Management and Mindfulness
10–20 min/day evidence-based practice
Mechanism

Chronic stress maintains high cortisol, which disrupts sleep architecture, suppresses immune function, and amplifies pain and fatigue perception. Mindfulness-based stress reduction (MBSR) lowers cortisol and improves fatigue in multiple chronic conditions.

Practical

Headspace, Calm, or NHS-approved apps; MBSR 8-week programme; refer to NHS Talking Therapies for formal psychological support; CBT for fatigue catastrophising; ACT (Acceptance and Commitment Therapy) for ME/CFS.

MBSR reduces fatigue severity in cancer survivors, IBD, and chronic fatigue by 30–40%
🚫
Alcohol and Substance Review
AUDIT-C; <14 units/wk (women <11)
Mechanism

Alcohol suppresses REM sleep (even at moderate intake), causes rebound wakefulness in the early hours, depletes B vitamins, and is a CNS depressant that causes next-day cognitive fatigue and low mood.

Practical

AUDIT-C at all fatigue consultations; brief alcohol intervention (FRAMES) if AUDIT-C positive; safe limits framing; support to reduce (Drinkaware, local alcohol service); advise no alcohol within 3 hours of bedtime to protect sleep architecture.

Reducing alcohol to safe limits improves sleep quality and fatigue significantly within 2–4 weeks
7D β€” Prescribing guide: what to start, in what order, and why
Treatment of fatigue is cause-specific β€” there is no non-specific fatigue prescription. The prescribing framework below covers the most common treatable causes in primary care: anaemia (iron/B12/folate), hypothyroidism (levothyroxine), depression (SSRIs), and diabetes (metformin). For ME/CFS, prescribing plays a supportive role β€” there is no disease-modifying drug. For OSA, CPAP is the treatment.
Iron Deficiency β€” Oral Iron Replacement

Ferrous sulfate 200mg TDS (or ferrous fumarate 210mg BD if better tolerated) β€” take on empty stomach, with vitamin C to improve absorption.

  • Continue for 3 months after Hb normalises to replete stores
  • FBC recheck at 4–6 weeks β€” Hb should rise by β‰₯10 g/L; if not, re-evaluate cause
  • Always investigate and treat the underlying cause (HMB, coeliac, GI bleed)
  • In women with HMB: combined OCP, progestogen-only, or tranexamic acid alongside iron
Hb <70 g/L + haemodynamic instability β†’ admit for transfusion assessment
Hypothyroidism β€” Levothyroxine

Levothyroxine 50mcg OD (25mcg in elderly or cardiac disease) β€” take 30–60 min before food, away from calcium/iron/PPI.

  • Recheck TSH at 6–8 weeks; target TSH 0.5–2.5 mU/L (symptom-guided in some patients)
  • Titrate in 25mcg increments; review at each increment
  • Hashimoto's: anti-TPO antibodies positive; follow TSH annually even if euthyroid
  • Subclinical hypothyroidism (TSH 4.5–10, normal free T4): treat if symptomatic or planning pregnancy
⚠ Do NOT start at full dose in elderly β€” risk of precipitating AF or angina
Depression β€” SSRI + NHS Talking Therapies

Sertraline 50mg OD (first-line per NICE NG222 β€” safest in cardiac disease and for drug interactions) β€” take in the morning; onset 2–4 weeks.

  • Always pair with NHS Talking Therapies referral β€” combined approach significantly superior to medication alone
  • Review at 2 weeks (tolerability, suicide risk), then 4–6 weeks (response)
  • If no response at 4–6 weeks at 50mg β†’ increase to 100mg; if still no response β†’ switch class
  • Continue for minimum 6 months after remission to prevent relapse
⚠ Review suicide risk at 2-week appointment β€” SSRIs increase energy before mood lifts, transiently increasing risk
B12 / Folate Deficiency + Diabetes + Addison's
  • B12 deficiency: Hydroxocobalamin 1mg IM every other day Γ— 6 doses (pernicious anaemia or neurological features); then every 3 months; dietary deficiency β†’ cyanocobalamin oral tablets
  • Folate deficiency: Folic acid 5mg OD for 4 months; investigate malabsorption; dietary advice
  • Type 2 diabetes: Metformin 500mg OD with food, titrate over 4 weeks to 1g BD; refer to diabetes structured education programme (DESMOND)
  • Addison's disease: Hydrocortisone 10mg morning + 5mg lunchtime (endocrinology prescribed); fludrocortisone; sick day rules; steroid emergency card β€” medic-alert bracelet
ME/CFS and OSA β€” Non-pharmacological primary treatments
  • ME/CFS: Pacing (energy management) β€” first-line; sleep management programme; specialist referral; low-dose amitriptyline if sleep disruption severe; melatonin if circadian rhythm disruption; low-dose naltrexone (specialist only)
  • ME/CFS β€” what NOT to do: Do NOT prescribe graded exercise therapy (GET); do NOT refer for CBT alone as primary treatment; do NOT attribute to psychiatric illness
  • OSA: CPAP machine (via sleep clinic) β€” first-line; weight loss; positional therapy; mandibular advancement device (mild-moderate OSA)
  • DVLA for OSA: Must notify DVLA and stop driving if daytime sleepiness until CPAP established and controlled; Group 2 licences (HGV/bus) β€” stricter rules apply
7E β€” Medication selection tool β€” choose diagnosis for tailored drug recommendation

Select the confirmed or suspected fatigue diagnosis β€” drug recommendation appears below

Drug / treatment recommendation
Select the fatigue diagnosis above to see tailored treatment recommendation
7F β€” Drug reference cards: treatment of the most common causes of fatigue
Ferrous Sulfate (Iron)
Ferrous sulfate Β· Ferrous fumarate Β· Ferrous gluconate
βœ“ Recommended
First-line 200mg TDS (or 210mg BD)
βœ“ Prefer when
Confirmed iron deficiency (ferritin <30 ΞΌg/L) with or without anaemia
Women with heavy menstrual bleeding and fatigue
Vegans, vegetarians, or those with poor dietary iron intake
Coeliac disease (ensure gluten-free diet compliance first)
βœ— Avoid if
Haemochromatosis or haemolytic anaemia β€” iron overload risk
Concurrent antacid or PPI use β€” markedly reduces absorption; separate by 2 hours
Inflammatory anaemia (anaemia of chronic disease) β€” iron supplementation alone is ineffective; treat underlying condition
⚠ Side effects
GI intolerance (nausea, constipation, diarrhoea) β€” very common; take with food if needed despite reduced absorption
Black stools β€” warn the patient explicitly (this is expected, not GI bleeding)
Teeth staining with liquid preparations β€” use straw
πŸ”¬ Monitor
FBC at 4–6 weeks β€” Hb should rise β‰₯10 g/L; ferritin at 3 months (replete stores)
If inadequate response: check compliance, absorption (coeliac screen), and ongoing blood loss
πŸ’¬ Counselling

"Take this on an empty stomach with a glass of orange juice if you can tolerate it β€” the vitamin C helps your body absorb the iron. Your stools will turn black β€” this is completely normal and not a sign of bleeding. If you get an upset stomach, try taking it with food."

Always investigate the cause of iron deficiency β€” it is never a diagnosis in itself. Missing GI malignancy in an iron-deficient patient over 50 is a serious clinical error and SCA examiner fail.

Levothyroxine (T4)
Levothyroxine sodium Β· Eltroxin Β· Accord brand
βœ“ Recommended
First-line 50mcg OD (25mcg in elderly)
βœ“ Prefer when
TSH >10 mU/L (treat regardless of symptoms)
TSH 4.5–10 mU/L with symptoms or in women planning pregnancy
All ages β€” hypothyroidism is a diagnosis, not a symptom, at any TSH level above reference range
Hashimoto's thyroiditis with raised TSH and positive anti-TPO antibodies
βœ— Avoid if
Untreated adrenal insufficiency β€” levothyroxine can precipitate adrenal crisis; treat with hydrocortisone first
Uncontrolled AF or recent MI β€” start at 25mcg with cardiologist input; titrate very slowly
⚠ Side effects
Overdose effects: palpitations, tremor, weight loss, sweating, AF β€” check TSH if these develop
Insomnia if taken in the evening β€” always take in the morning
Drug interactions: calcium, iron, PPIs, cholestyramine all reduce absorption β€” take 30–60 min before food
πŸ”¬ Monitor
TSH at 6–8 weeks after initiation or dose change; then annually once stable
Target TSH: 0.5–2.5 mU/L (some patients feel better at lower end of range)
Free T4 if TSH suppressed (to distinguish adequate replacement from hyperthyroidism)
πŸ’¬ Counselling

"Take this tablet every morning, ideally 30–60 minutes before breakfast on an empty stomach. Don't take it at the same time as your iron or calcium tablets. You'll need a blood test in 6–8 weeks to check the dose is right β€” most people feel better within that time, but full benefits can take a few months."

Never start levothyroxine without first excluding adrenal insufficiency in a patient who might have both conditions (e.g. autoimmune polyendocrine syndrome). Doing so can precipitate an adrenal crisis.

SSRIs (for depression-related fatigue)
Sertraline Β· Citalopram Β· Fluoxetine Β· Escitalopram
βœ“ Recommended
First-line Sertraline 50mg OD
βœ“ Prefer when
PHQ-9 β‰₯10 (moderate-severe depression) with fatigue as predominant complaint
Sertraline: first-line in cardiac disease, safest drug interaction profile
Mirtazapine: if significant insomnia or anorexia (sedating, appetite-stimulating)
Always combine with NHS Talking Therapies referral β€” combination superior to either alone
βœ— Avoid if
MAOI within 14 days (serotonin syndrome)
Do NOT use in ME/CFS as primary treatment for fatigue β€” SSRIs do not treat ME/CFS and may worsen symptoms
Pregnancy (consult prescribing team β€” some SSRIs have better safety profiles than others; sertraline preferred)
⚠ Side effects
Initial: nausea, agitation, sleep disturbance, headache (usually resolves in 2 weeks)
Ongoing: sexual dysfunction, emotional blunting, weight change
Discontinuation syndrome β€” must taper when stopping; do not stop abruptly
πŸ”¬ Monitor
2-week review: tolerability, suicide risk (SSRIs increase energy before mood β€” transient risk)
4–6 week review: PHQ-9 response; if <50% improvement β†’ increase dose or switch agent
6-month minimum continuation after remission to prevent relapse
πŸ’¬ Counselling

"This medication takes 2–4 weeks to start working β€” many people feel slightly worse before they feel better. It doesn't make you a different person, it just reduces the chemical imbalance that's driving how you feel. I want to see you in 2 weeks to check how you're getting on, and please contact us immediately if you feel your thoughts become very dark."

Always review at 2 weeks after SSRI initiation β€” this is NICE NG222 mandatory. SSRIs briefly increase energy before improving mood, transiently increasing suicide risk. Missing this review is an SCA deduction.

Hydroxocobalamin (Vitamin B12)
Hydroxocobalamin injection Β· Cyanocobalamin oral
βœ“ Recommended
First-line 1mg IM alternate days Γ— 6 doses
βœ“ Prefer when
Confirmed B12 deficiency (<180 pmol/L) with neurological features β€” IM injection mandatory
Pernicious anaemia (positive intrinsic factor antibodies) β€” lifelong IM maintenance
Vegans/vegetarians without neurological features β€” high-dose oral cyanocobalamin acceptable
Metformin-related B12 deficiency β€” check B12 annually in all patients on long-term metformin
βœ— Avoid if
Polycythaemia or Leber's optic neuropathy β€” hydroxocobalamin still used but with caution; specialist input
⚠ Side effects
Injection site reactions (pain, redness) β€” rotate sites
Acne β€” can occur with B12 loading doses; usually self-limiting
Allergic reactions (rare) β€” have resuscitation facilities available for first injection
πŸ”¬ Monitor
FBC at 8 weeks β€” expect Hb rise and MCV normalisation
Potassium in first 48 hours of loading doses (hypokalaemia risk as bone marrow recovers)
Pernicious anaemia: lifelong 3-monthly IM injections; annual B12 level not needed once on maintenance
πŸ’¬ Counselling

"You'll be having a course of B12 injections over the next 2–3 weeks to top up your levels quickly. After that, if this is due to pernicious anaemia, you'll need an injection every 3 months for life β€” this isn't a failure, it's just how the condition works. Most people notice a significant improvement in energy within a few weeks of starting."

Always investigate why B12 is low before treating β€” pernicious anaemia (intrinsic factor antibodies), coeliac disease, or GI malignancy may be the underlying cause. Treating without investigating may mask a serious diagnosis.

Metformin (for T2DM-related fatigue)
Metformin hydrochloride Β· Glucophage Β· Sukkarto SR
βœ“ Recommended
First-line 500mg OD with food; titrate
βœ“ Prefer when
HbA1c β‰₯48 mmol/mol with fatigue as presenting symptom
Obesity + insulin resistance β€” metformin reduces hepatic glucose output and improves insulin sensitivity
Combination with lifestyle intervention (weight loss, dietary change) β€” synergistic effect
CV risk reduction β€” metformin has cardiovascular protection beyond glucose lowering (UKPDS data)
βœ— Avoid if
eGFR <30 β€” increased lactic acidosis risk; hold at eGFR <45 if contrast media being given
Severe liver disease or alcohol excess β€” impairs lactate clearance
Hospitalisation or major surgery β€” hold peri-operatively; restart when eating and drinking
⚠ Side effects
GI intolerance (nausea, diarrhoea) β€” very common; take with food; SR formulation reduces GI side effects
B12 deficiency with long-term use β€” check B12 annually in patients on metformin >1 year
Metallic taste β€” common but usually transient
πŸ”¬ Monitor
HbA1c at 3 months (confirm glucose lowering), then every 3–6 months until stable
eGFR annually (or more frequently if CKD) β€” dose adjust at eGFR <45
B12 annually with long-term use; check if macrocytic anaemia develops
πŸ’¬ Counselling

"Take this tablet with your largest meal to reduce the chance of an upset stomach. It works by helping your body use the sugar in your blood more effectively β€” which is why it will help with your energy levels as well as your blood sugar. We'll check your blood results in 3 months to see how well it's working."

Metformin can cause B12 deficiency β€” check B12 annually in all patients on long-term metformin. This is a commonly missed monitoring requirement in SCA and real-world practice alike.

Amitriptyline (sleep in ME/CFS)
Low-dose supportive β€” NOT antidepressant dose
βœ“ Recommended
Supportive 10–25mg nocte
βœ“ Prefer when
ME/CFS with significant sleep disruption as predominant secondary symptom
Neuropathic pain component to ME/CFS (allodynia, widespread pain)
Fibromyalgia with fatigue and sleep disruption β€” evidence for symptomatic benefit
Chronic fatigue with insomnia not responding to sleep hygiene alone
βœ— Avoid if
Recent MI or significant QTc prolongation β€” cardiac risk
Acute closed-angle glaucoma
Elderly (falls, anticholinergic burden, confusion) β€” lowest dose; falls assessment first
⚠ Side effects
Morning hangover / drowsiness (take 1–2 hours before bed; start at lowest dose)
Dry mouth, constipation, urinary hesitancy β€” anticholinergic effects
Weight gain with prolonged use
πŸ”¬ Monitor
Sleep quality and morning function at 4–6 weeks
Falls risk in elderly; anticholinergic burden score if multiple CNS-active drugs
ECG if cardiac risk factors present before initiation
πŸ’¬ Counselling

"This is at a very low dose β€” much lower than what would be used for depression. At this dose, it helps to improve the quality of your sleep. Take it about an hour before bed; you may feel a bit groggy in the morning at first, but this usually settles. It's not habit-forming at this dose."

When prescribing amitriptyline for ME/CFS, explicitly clarify that this is for sleep support, not because the fatigue is psychiatric. Failing to make this distinction causes significant patient distress and is an SCA Relating to Others deduction.

7G β€” Psychosocial impact of the diagnosis: relationships, work, identity & daily life
πŸ«‚
Living with Fatigue β€” the impact on identity, relationships, and functioning
Chronic fatigue, regardless of aetiology, has profound psychosocial consequences. Patients with ME/CFS in particular have often experienced years of disbelief from clinicians, employers, and family members β€” the act of giving a valid diagnosis is itself therapeutic. Proactively discussing these impacts, and providing practical guidance on entitlements and support, is a core part of management.
πŸ’Ό
Work and Occupational Function

Fatigue significantly impairs work performance β€” concentration, memory, and stamina are all affected. Many patients fear job loss or have already taken significant sick leave.

Fit notes should be diagnosis-specific and time-limited. For ME/CFS: "May be fit for work with adaptations β€” reduced hours, working from home, no overtime." Occupational health referral should be offered early.

Universal Credit / Personal Independence Payment (PIP) may be applicable for those with ME/CFS or other disabling fatigue conditions β€” GP letters of support may be needed.

"Let's talk about your work situation β€” there may be adjustments we can help you put in place so you don't have to be completely off sick."
πŸš—
Driving and Transport

OSA with Epworth >15 or unexplained episodes of drowsiness while driving must be disclosed to DVLA and driving must cease until controlled with CPAP. This is a legal obligation and must be communicated clearly.

Severe ME/CFS or depression-related cognitive impairment may affect driving safety β€” patients must self-assess; if in doubt, advise cessation and DVLA notification.

Medications causing sedation (opioids, amitriptyline, sedating antihistamines) impair driving β€” document counselling in the notes.

"Because of the sleep apnoea, I need to ask you to stop driving until we have a CPAP machine in place and your sleep is controlled β€” this is a legal requirement, not just advice."
πŸ’‘
Relationships and Social Life

Chronic fatigue strains relationships. Partners may not understand an invisible illness. Sexual function is directly impaired by fatigue, depression, hypothyroidism, and medication side effects (SSRIs, opioids).

Social withdrawal due to fatigue worsens mood and perpetuates the cycle. Social prescribing β€” gentle activity groups, peer support for ME/CFS β€” can reduce isolation without triggering PEM.

Family members may dismiss ME/CFS as "laziness" β€” providing written information for the family is clinically valuable.

"Has this been affecting your relationship or your social life? Fatigue of this kind can put a real strain on the people around you too β€” it might be worth thinking about how we support the whole picture."
🧠
Cognitive Function ("Brain Fog")

Cognitive dysfunction (brain fog) β€” impaired memory, concentration, and word-finding β€” accompanies ME/CFS, hypothyroidism, severe depression, and anaemia. It is frequently the most disabling symptom for working-age adults.

Treatment of the underlying cause often improves cognition significantly (levothyroxine for hypothyroidism; iron for anaemia; SSRIs for depression). In ME/CFS, pacing reduces cognitive crashes.

Inform employers: cognitive symptoms qualify for reasonable adjustments under the Equality Act 2010 in diagnosed conditions.

"The 'brain fog' you're describing is a recognised symptom of this condition β€” it's not you losing your mind; it's a consequence of how your body is functioning right now, and it often improves significantly with treatment."
πŸ›‘οΈ
Benefits, Financial Impact, and Legal Rights

Chronic disabling fatigue (particularly ME/CFS and severe depression) may qualify for Statutory Sick Pay, ESA, PIP, or Universal Credit. GPs are frequently asked for supporting letters β€” it is appropriate to provide factual letters documenting diagnosis, function, and prognosis.

Under the Equality Act 2010, a condition substantially affecting normal daily activities for 12 months constitutes a disability. ME/CFS, hypothyroidism, and treated depression may all qualify.

Social prescribing link workers can support navigation of the benefits system β€” consider referral.

"Given how much this is affecting your daily life and work, it's worth exploring whether you might be entitled to any financial support β€” I can provide a letter to support a benefits application if that would help."
🌟
Identity and the Illness Experience

Patients with unexplained or ME/CFS-related fatigue have often been dismissed by previous clinicians, labelled as anxious or depressed without proper assessment, or told "your tests are normal" as if that dismisses their symptoms.

Validating the diagnosis β€” "this is a real, recognised medical condition" β€” and acknowledging their previous experience is itself therapeutic and reduces reconsultation frequency.

Peer support networks (ME Association, Action for ME) and patient education improve self-efficacy and reduce dependency on the healthcare system.

"I want to be clear: what you're experiencing is real, it's recognised, and it has a name. I'm sorry it's taken this long to get here β€” let's focus on what we can actually do to help."
7H β€” Follow-up schedule
1
2–3 weeks β€” Blood results review

Review full fatigue blood panel results with the patient. If organic cause found: initiate treatment and explain plan. If normal: discuss psychosocial causes; administer or review PHQ-9; arrange further investigation if red flag features now identified. Adjust investigation based on clinical picture evolution.

Results reviewPHQ-9 if not yet doneTreatment initiation
2
4–6 weeks β€” Treatment response review

Assess response to initiated treatment (iron, levothyroxine, sertraline). PHQ-9 if depression diagnosed. Side effect review for new medications. SSRI β€” mandatory 2-week and 4–6-week reviews (NICE NG222). Iron β€” FBC re-check at 4–6 weeks. TSH re-check at 6–8 weeks. Review NHS Talking Therapies referral status if depression diagnosed.

SSRI 2-week (mandatory)FBC / TSH re-checkNHS Talking Therapies status
3
3 months β€” Chronic fatigue threshold / ME/CFS assessment

If fatigue persists despite treatment of identified organic causes, formally assess for ME/CFS criteria: PEM + unrefreshing sleep + cognitive dysfunction + β‰₯3 months duration. Specialist ME/CFS referral if criteria met. Review and deprescribe any medications contributing to fatigue (beta-blockers, sedating agents).

ME/CFS criteriaSpecialist referral if indicatedMedication review
4
6 months β€” Structured chronic fatigue review

Review response to ME/CFS management (pacing, specialist input). PHQ-9 monitoring if depression treated. Annual thyroid function if on levothyroxine or Hashimoto's. Annual HbA1c if diabetes. Review benefit entitlements if still significantly impaired. Update fit note if applicable.

Annual monitoring checksPHQ-9 / function review
5
Annual β€” Long-term fatigue and chronic disease review

Annual structured review: thyroid function (levothyroxine patients); HbA1c (diabetes); FBC + ferritin (iron deficiency); B12 (pernicious anaemia 3-monthly injections; long-term metformin annually); PHQ-9; functional status; medication review; social prescribing update; ME/CFS progress and NICE NG206 compliance check.

Annual bloods panelPHQ-9Medication review
7I β€” Monitoring: cause-specific targets and review intervals

Memory rule β€” Fatigue Monitoring: TRIBES

Thyroid (TSH at 6–8 weeks, annually) Β· Reticulocyte/FBC response (4–6 weeks for iron/B12) Β· Insulin / HbA1c (3-monthly until stable) Β· B12 (3-monthly IM injections for pernicious anaemia; annually for metformin users) Β· Energy management (ME/CFS pacing review at 3 months) Β· Suicide / PHQ-9 (2-week SSRI review; PHQ-9 at every depression contact)

TreatmentTestTimingAction threshold
Ferrous sulfate (iron)FBC + ferritin4–6 weeks; ferritin at 3 monthsHb rise <10 g/L at 4 weeks β†’ check compliance, malabsorption, ongoing blood loss; ferritin <30 at 3 months β†’ continue iron
Levothyroxine (hypothyroidism)TSH (Β± free T4)6–8 weeks after initiation or dose change; annually when stableTSH >2.5 β†’ increase dose by 25mcg; TSH <0.1 β†’ reduce dose; free T4 if TSH suppressed
Sertraline / SSRI (depression)PHQ-9 + clinical assessment2 weeks (mandatory safety review); 4–6 weeks (response); 3-monthly during treatmentPHQ-9 no improvement at 6 weeks at therapeutic dose β†’ increase dose or switch agent; PHQ-9 item 9 positive (suicidal ideation) β†’ crisis assessment same day
Hydroxocobalamin (B12 deficiency)FBC + MCV + serum B128 weeks after loading doses; K⁺ in first 48h of loadingNo FBC response at 8 weeks β†’ re-check diagnosis; potassium <3.5 mmol/L in first days β†’ correct hypokalaemia
Metformin (T2DM)HbA1c + eGFR + B12HbA1c: 3-monthly until stable; eGFR: annually; B12: annuallyHbA1c >58 at 3 months β†’ escalate treatment (add SGLT2i or DPP-4i); eGFR <45 β†’ reduce dose; B12 low β†’ supplementation
Condition / patient groupTargetReview interval
Hypothyroidism on levothyroxineTSH 0.5–2.5 mU/L (symptom-guided)6–8 weeks after dose change; annually when stable
Iron deficiency anaemiaHb >120 (F) / 130 (M) g/L; ferritin >50 ΞΌg/L4–6 weeks (FBC); 3 months (ferritin); annually if HMB ongoing
Depression (PHQ-9)PHQ-9 <10 (response); <5 (remission)2 weeks post-SSRI initiation; 4–6 weeks; 3-monthly during treatment
Type 2 diabetesHbA1c ≀48 mmol/mol (individualised)3-monthly until stable; 6-monthly when controlled
Pernicious anaemia (B12)B12 >200 pmol/L (not routinely checked on IM)3-monthly IM hydroxocobalamin injections β€” lifelong
ME/CFS (functional status)Energy envelope stable; PEM not triggered3-monthly specialist reviews; annual GP structured review
7J β€” Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases β€” use these verbatim

πŸ”΄ Emergency β€” new red flag features in fatigue
"While we're waiting for the blood tests, I need you to come back immediately β€” or go to A&E β€” if you develop any of the following: fever that won't go away, unexplained weight loss, or you notice any new lumps. These are the symptoms that would tell me we need to act more urgently than we'd planned."
Naming the specific features that would change the triage category is medico-legally protective. Vague safety-netting ("come back if anything changes") is insufficient if a patient subsequently presents with lymphoma having been sent home from a fatigue consultation. This phrasing demonstrates you considered and communicated the malignancy risk.
πŸ’Š Medication β€” SSRI initiation safety-net (depression)
"I'm starting you on an antidepressant today, and I want to be honest about the first couple of weeks. Some people feel slightly more anxious or agitated when they first start β€” this is temporary. More importantly: if at any point your thoughts become very dark, or you find yourself thinking about harming yourself, please contact us that day or go to A&E. Don't wait for your follow-up appointment."
NICE NG222 mandates suicide risk assessment at 2 weeks after SSRI initiation. SSRIs increase energy before lifting mood β€” this is the period of highest risk. Failing to give this safety-net when prescribing an SSRI is a clinical governance failure and an SCA deduction.
🟠 ME/CFS β€” crash / PEM warning and when to return
"If you try to do too much and experience a significant worsening of your symptoms β€” the kind that lasts more than 24 hours β€” I want you to rest rather than push through, and let me know at your next appointment. And if you develop any new symptoms β€” fever, significant weight loss, or new neurological problems β€” I want you to come back sooner, as these would not be typical of ME/CFS and would need investigation."
Distinguishing ME/CFS symptom fluctuation (normal) from new pathology is critical. ME/CFS patients can develop co-morbid conditions that are missed by attributing all new symptoms to ME/CFS. This safety-net establishes when new symptoms warrant reassessment and prevents both over- and under-investigation.
2–3 weeks: Blood results review; PHQ-9 if not done; start treatment if organic cause found
2 weeks (SSRI): Mandatory NICE review β€” tolerability + suicide risk assessment
Urgent / A&E: New B symptoms; active suicidal ideation; Addisonian crisis features
πŸŽ“ SCA Checkpoint β€” Step 7 (Final)TasksRelating to OthersGlobal Skills
Closing the consultation
"To summarise: based on what you've told me, I'm going to run a blood panel to check the most common treatable causes. I'd also like you to complete this mood questionnaire."
"While we wait for the results, here are some things that are likely to help regardless of what comes back β€” particularly around sleep and activity."
"I want you to come back in 2–3 weeks to go through the results together, and sooner if you notice fever, weight loss, or any new lumps."
"If we're starting you on medication today, I need to see you in 2 weeks β€” and if at any point you feel like harming yourself, please contact us the same day."
"Before you go β€” is there anything we haven't covered, or anything else on your mind?"
Deductions β€” closing
  • Not using PHQ-9 in a patient presenting with fatigue
  • Recommending graded exercise therapy to a patient with ME/CFS (NICE NG206 contra-indicated)
  • Initiating SSRI without arranging mandatory 2-week review or giving suicide safety-net
  • Ordering no investigations in a patient with >4 weeks of unexplained fatigue
  • Attributing all fatigue to stress or lifestyle without organic screen
  • Not addressing cancer fear explicitly when it was the hidden concern
Tasks domain β€” full criteria
  • Full red flag screen completed (B symptoms, weight loss, lymphadenopathy)
  • Standard fatigue blood panel arranged with rationale explained
  • PHQ-9 used as validated depression screen
  • PEM asked and ME/CFS considered if appropriate
  • Diagnosis communicated in plain language with specific management plan
Relating to Others β€” full criteria
  • ICE fully explored β€” cancer fear, expectation for investigations, illness model
  • Fatigue validated as real and taken seriously β€” not dismissed as "stress"
  • ME/CFS: diagnosis acknowledged as real medical condition, not psychiatric
  • Patient's expectation negotiated β€” investigation plan agreed, not imposed
  • Depression discussed empathetically β€” stigma addressed if raised
  • Closing question asked β€” "anything else on your mind?"
πŸ”΄ Red β€” failing
No PHQ-9; no red flag screen; recommends GET for ME/CFS; no SSRI safety-net; attributes fatigue to "stress" without investigation; dismisses cancer concern; no investigation plan for 3-month fatigue.
🟠 Amber β€” borderline
PHQ-9 mentioned but not used; blood panel ordered but not explained; red flags partially covered; cancer fear not explicitly addressed; SSRI prescribed without safety-net; diagnosis given but no plain-language explanation.
🟒 Green β€” passing
PHQ-9 used; full red flag screen; blood panel with patient-friendly rationale; cancer fear explicitly addressed and ruled out; diagnosis in plain language; PEM asked and ME/CFS considered; SSRI with 2-week review and safety-net; closing question asked.
Fatigue & Tiredness β€” SCA Consultation Scorecard
Based on the official SCA Consultation Tool Β· RAG self-assessment Β· Use after every practice consultation
0 / 33 pts
🌐
Global Skills
Structure, language, responsiveness
0/7
βœ“
Tasks
Clinical reasoning, diagnosis, management
0/15
🀝
Relating to Others
Communication, rapport, shared decision making
0/11
RAG Self-Assessment Guide
πŸ”΄ Red β€” not achieved
No PHQ-9; no red flag screen; recommends GET for ME/CFS; SSRI without safety-net; no investigation plan; dismisses fatigue as stress; cancer fear not addressed.
🟠 Amber β€” partially achieved
PHQ-9 mentioned but not used; red flags partially covered; blood panel ordered but not explained; cancer fear not proactively addressed; SSRI prescribed without 2-week review arranged.
🟒 Green β€” fully achieved
PHQ-9 used; full red flag screen; blood panel with rationale; cancer fear explicitly addressed; PEM asked; fatigue validated; diagnosis plain language; safety-nets given; 2-week SSRI review; closing question asked.
011172533
Fail
Borderline
Pass
Strong pass
πŸ“‹
Complete the checklist above to see your score interpretation and feedback
"I've been absolutely exhausted for the past 4 months and it's getting worse, not better. I was hoping I could get some blood tests done β€” maybe my iron is low or something like that."
Who you are

Sarah, 36 years old, secondary school teacher. 4-month history of worsening fatigue β€” exhausted from the moment she wakes up, unable to exercise, struggling to concentrate on marking and planning. Has missed several social events she previously looked forward to. Attributing it to a demanding teaching job, but it has got to the point where she can no longer cope. She has two children (ages 4 and 7) and is the primary carer as her partner works away. She has been telling herself it's "just stress."

Hidden agenda

Sarah's mother was diagnosed with lymphoma 2 years ago and is currently in remission. Sarah has been quietly terrified for months that this fatigue is the same thing. She has not told her partner because she doesn't want to worry him. She would like "the full blood tests" partly for iron deficiency but primarily to rule out cancer. She will only feel genuinely reassured if the doctor directly asks about and addresses this fear β€” simply ordering bloods without acknowledging the cancer worry will leave her anxious and unsatisfied.

Symptoms if asked directly
  • Fatigue: 8/10 severity; present from waking; no diurnal variation
  • Unrefreshing sleep β€” wakes up exhausted even after 8 hours
  • Periods: regular, moderately heavy (4–5 days, changing pad 4Γ— daily on heaviest day)
  • No weight loss β€” if anything, gained 2–3 kg from inactivity
  • No fever, no night sweats, no lumps
  • Concentration: significantly impaired β€” "can't hold a thought"
  • Mood: low, tearful at times, but no anhedonia volunteered unless directly asked
  • No suicidal ideation
  • If asked specifically about enjoying things: "Not really β€” I used to love running, haven't done it in months"
  • No PEM β€” activity doesn't specifically worsen fatigue the next day beyond general tiredness
Lifestyle + bonus details
  • Diet: poor β€” skips breakfast, eats lunch quickly, relies on convenience food in evenings
  • Alcohol: 10–12 units/week, mostly wine in evenings "to unwind"
  • No medications; stopped iron tablets 2 years ago (prescribed in pregnancy) after she ran out
  • No family history of thyroid disease; mother had lymphoma (Non-Hodgkin's, now in remission)
  • Bonus detail (only if doctor asks about family history of illness): "My mum had lymphoma β€” that's actually part of why I'm here today, if I'm honest."
"Look β€” I know you want to run tests, but I've been Googling my symptoms and I'm really worried this could be something serious. My mum had lymphoma and she was just tired at first. Can you tell me honestly whether you think that's a possibility?"

Resolution: Sarah will accept the plan if the doctor (1) explicitly names and addresses the lymphoma / cancer fear β€” proactively, not just after the challenge; (2) explains the clinical features that distinguish iron deficiency + depression from malignancy (no B symptoms, no lymphadenopathy on examination, no weight loss, plausible alternative cause with HMB); (3) arranges blood tests that include the malignancy screen (FBC, ESR, LFTs); (4) uses PHQ-9 and addresses her mood; (5) gives a specific follow-up appointment to review results and offers the option to call if symptoms change significantly before then.

πŸ₯
Clinic Quick Reference
Fatigue & Tiredness β€” Clinical Decision Framework
NICE CKS 2024 Β· NICE NG206 (ME/CFS) Β· NICE NG222 (Depression) Β· Multiple guidelines
β–Όexpand
🚦 1 β€” Triage System
Patient presents with fatigue β†’ red flag screen first: B symptoms? Weight loss? Suicidal ideation?
↓
πŸ”΄ Emergency / same-day hospital
  • Adrenal crisis (collapse + hypotension + vomiting)
  • Severe anaemia with haemodynamic instability (Hb <70 + cardiac compromise)
  • Active suicidal ideation with intent or plan
  • Acute leukaemia (abnormal FBC with blasts)
  • MSCC in cancer patient with new neurology
999 / same-day crisis team
🟠 Urgent β€” 24–72 hours
  • B symptoms (fever + night sweats + weight loss) β†’ 2WW haematology
  • Unexplained weight loss β‰₯5% + fatigue (age >40)
  • Suspected Addison's (postural dizziness + hyperpigmentation)
  • PHQ-9 β‰₯15 with safeguarding concern / suicidal ideation
  • New heart failure suspected (fatigue + BNP elevated)
Same-day bloods + urgent referral
🟒 Routine β€” primary care
  • Fatigue >4 weeks, no red flags β†’ standard fatigue panel + PHQ-9
  • Depression (PHQ-9 <15, no risk) β†’ SSRI + NHS Talking Therapies
  • Iron deficiency / hypothyroidism confirmed β†’ treat and review
  • ME/CFS suspected β†’ pacing + specialist referral
Standard fatigue panel + review 2–3 weeks
πŸ”¬ 2 β€” Diagnostic Pathway
Standard Fatigue Blood Panel (all unexplained fatigue >4 wks)
βœ“ FBC (anaemia, leukaemia, thrombocytopaenia)
βœ“ TSH (hypothyroidism / hyperthyroidism)
βœ“ HbA1c (diabetes)
βœ“ Ferritin + serum iron (iron deficiency β€” especially women)
βœ“ CRP + ESR (inflammatory / malignancy screen)
βœ“ LFTs (hepatic disease, alcohol, malignancy)
βœ“ U&E + eGFR + calcium (renal disease, Addison's, myeloma)
βœ“ B12 + folate (nutritional deficiency, pernicious anaemia)
βœ“ PHQ-9 (depression β€” mandatory validated tool, not clinical impression)
Additional Investigations β€” clinically indicated
Monospot / EBV titres: Post-viral fatigue, young adult, pharyngitis
HIV test: Risk factors, recurrent infections, generalised lymphadenopathy
9am cortisol: Suspected Addison's (postural hypotension, hyperpigmentation)
SPEP + BJP: ESR >100, bone pain, hypercalcaemia β†’ myeloma screen
ANA + anti-dsDNA: Butterfly rash, joint pain, thrombocytopaenia β†’ SLE screen
PSA: Male >50 with unexplained fatigue
STOP-BANG + Epworth: Snoring, witnessed apnoeas, obese β†’ OSA screen
LDH: B symptoms + lymphadenopathy β†’ lymphoma screen
πŸ“Š 3 β€” Key Numbers
PHQ-9 β‰₯10
Moderate depression β€” treat actively
Hb <120/130
Anaemia threshold F/M (g/L)
TSH >10
Treat hypothyroidism regardless of symptoms (mU/L)
HbA1c β‰₯48
Diagnose T2DM (mmol/mol)
Ferritin <30
Iron deficiency even with normal Hb (ΞΌg/L)
B12 <180
Treat deficiency with IM hydroxocobalamin (pmol/L)
3 months
ME/CFS minimum duration criterion
6–8 weeks
Recheck TSH after levothyroxine initiation
2 weeks
Mandatory SSRI safety review (NICE NG222)
ESR >100
Myeloma / severe inflammatory disease screen
Epworth >10
Refer for sleep study (OSA)
PEM
Post-exertional malaise = ME/CFS hallmark; GET contra-indicated
πŸ’Š 4 β€” Medication Decision & Choice
Cause-Specific Treatment Algorithm
Iron deficiency: Ferrous sulfate 200mg TDS + vitamin C; FBC at 4 weeks; treat cause (HMB, coeliac)
Hypothyroidism: Levothyroxine 50mcg OD (25mcg if elderly); TSH at 6–8 weeks; target TSH 0.5–2.5
Depression: Sertraline 50mg OD + NHS Talking Therapies; 2-week mandatory review; 6-month minimum course
B12 deficiency: Hydroxocobalamin 1mg IM alternate days Γ— 6 doses; then 3-monthly if pernicious anaemia
T2DM: Metformin 500mg OD with food, titrate; HbA1c at 3 months; B12 annually
ME/CFS: NO pharmacological first-line treatment; pacing; specialist referral; sleep support (amitriptyline 10mg nocte if needed)
Important Prescribing Rules β€” Fatigue
β›” Do NOT start levothyroxine without excluding adrenal insufficiency first (risk of adrenal crisis)
β›” Do NOT recommend graded exercise therapy (GET) in ME/CFS β€” NICE NG206 explicitly contra-indicated
β›” Do NOT give iron without investigating the cause β€” iron deficiency is not a diagnosis in itself
β›” Do NOT prescribe SSRI without arranging 2-week review and giving suicide safety-net
βœ… Annual B12 monitoring for all patients on long-term metformin
βœ… Levothyroxine away from iron, calcium, PPIs (take 30–60 min before food)
⚠ 5 β€” Safety Netting & Follow-Up
πŸ”΄ Emergency β€” new red flags in fatigue
"Come back urgently β€” or go to A&E β€” if you develop fever that won't go away, unexplained weight loss, or notice any new lumps."
πŸ’Š SSRI safety-net β€” depression
"If your thoughts become very dark or you think about harming yourself, contact us the same day or go to A&E. Don't wait for your follow-up."
🟠 ME/CFS β€” PEM and new symptoms
"If you experience a significant worsening after activity, rest β€” don't push through. Any new fever, weight loss, or neurological symptoms: come back sooner."
Follow-up timeline
1
2 weeks (SSRI): Mandatory safety review β€” tolerability + suicide risk
2
2–3 weeks: Blood results review; start treatment; PHQ-9 review
3
4–6 weeks: Treatment response (FBC/TSH re-check; PHQ-9 response)
4
3 months: ME/CFS criteria assessment; medication review; specialist referral
5
Annual: Thyroid / HbA1c / B12 / FBC / PHQ-9 structured review
πŸ“Œ SSRI 2-week review is NICE NG222 mandatory β€” cannot be omitted
πŸ”¬ 6 β€” Monitoring & Red Flags
TreatmentTestTimingAction threshold
Ferrous sulfateFBC + ferritin4–6 weeks; ferritin at 3 monthsHb rise <10 g/L β†’ check compliance, cause, malabsorption
LevothyroxineTSH (Β± free T4)6–8 weeks; annually stableTSH >2.5 β†’ increase dose; TSH <0.1 β†’ reduce dose
Sertraline / SSRIPHQ-9 + clinical review2 weeks (mandatory); 4–6 weeksPHQ-9 item 9 positive β†’ crisis assessment same day; no response at 6 weeks β†’ dose increase or switch
MetforminHbA1c + eGFR + B12HbA1c: 3-monthly; eGFR/B12: annuallyeGFR <45 β†’ reduce dose; B12 low β†’ supplement
Hydroxocobalamin (IM)FBC + MCV + K⁺8 weeks post-loading; K⁺ in first 48hNo FBC response β†’ re-check diagnosis; K⁺ <3.5 β†’ correct
PHQ-9 monitoring (depression)PHQ-9Every GP contact during depression treatmentPHQ-9 β‰₯15 β†’ assess suicide risk; <5 = remission
🚨 Red flags β€” urgent action: B symptoms (fever + night sweats + weight loss); lymphadenopathy; unexplained weight loss >5%; active suicidal ideation; adrenal crisis features; FBC with blast cells
πŸ›‘οΈ Safeguarding: Fatigue from domestic abuse or coercive control; carer burnout with neglect risk; modern slavery features; parent with severe depression + children at home; adolescent with fatigue + school avoidance
πŸŽ“
SCA Exam Quick Reference
SCA Consultation Blueprint
Tasks Β· Relating to Others Β· Global Skills Β· RAG guide
β–Όexpand
πŸ• 12-Minute Consultation Flow β€” with Domain Scoring
0–2 min
Open & Red Flag Screen
"Tell me about this tiredness β€” what's it been like for you?"
Use case card info as your opener β€” do not re-ask documented facts. Let the patient lead for 60–90 seconds before any targeted questioning.
Red flag screen within first 2 minutes: B symptoms, weight loss, lymphadenopathy, suicidal ideation (if mood positive).
Tasks Global Skills
βœ— Re-asking documented info Β· βœ— No red flag screen Β· βœ— Starting with targeted systemic review without open question
2–5 min
Targeted History + ICE
"Is there anything about this tiredness that has really worried you β€” anything you've been hoping I could rule out?"
Cancer fear is the most common hidden concern. Probe for it directly β€” do not wait for the challenge.
Ask PEM specifically: "Does activity make the fatigue significantly worse the following day?" β€” changes management completely.
Tasks Relating to Others
βœ— No cancer fear probe Β· βœ— PEM not asked Β· βœ— ICE missed entirely Β· βœ— No mood screen
5–7 min
PHQ-9 + Examination
"I'd like you to complete this questionnaire about your mood β€” it helps me be precise about whether low mood is contributing to how you feel."
Targeted examination: lymph nodes, thyroid, conjunctival pallor, abdomen, BMI. Communicate findings explicitly.
PHQ-9 is mandatory for all fatigue β€” it is a Task, not just nice to have.
Tasks Global Skills
βœ— No PHQ-9 Β· βœ— Examination not signposted Β· βœ— Findings not communicated Β· βœ— Misses lymphadenopathy in B-symptom patient
7–10 min
Working Diagnosis + Expectation Management
"Based on what you've told me, I think the most likely causes are [X] β€” and I want to run tests to confirm. Importantly, I'm not finding features of [cancer / something more sinister]."
Explicitly address the cancer fear β€” don't assume the patient is reassured by a "normal examination." They need to hear it said.
Tasks Relating to Others
βœ— Not addressing cancer fear Β· βœ— Recommending GET if PEM positive Β· βœ— Ordering no investigations
10–12 min
Management Plan + Safety-Net + Close
"While we wait for results, let's talk about some things that are likely to help regardless. And I need you to know β€” if you develop fever, weight loss, or new lumps before we meet again, come back straight away."
Named follow-up: 2–3 weeks for results (+ 2 weeks if SSRI started). Safety-net: B symptoms + SSRI suicide risk.
Closing question: "Is there anything else on your mind?"
Tasks Relating to Others Global Skills
βœ— No safety-net for B symptoms Β· βœ— SSRI without suicide safety-net Β· βœ— No follow-up Β· βœ— No closing question
πŸ”΄πŸŸ πŸŸ’ RAG Scoring β€” All 3 Domains
Tasks Domain
🟒
Red flags all screened; PHQ-9 used; standard fatigue panel; PEM asked; correct diagnosis communicated; safety-net given; follow-up named
🟠
PHQ-9 mentioned not used; blood panel ordered not explained; PEM not asked; cancer fear not addressed; safety-net vague; no follow-up named
πŸ”΄
No PHQ-9; no red flag screen; recommends GET for ME/CFS; SSRI without safety-net; no investigation plan for 4-month fatigue
Relating to Others
🟒
ICE all three; cancer fear explicitly addressed; fatigue validated; ME/CFS acknowledged as real; depression discussed without stigma; shared decision making; closing question
🟠
ICE partially covered; cancer fear not proactively raised; fatigue not explicitly validated; depression discussion clinical not empathetic; no closing question
πŸ”΄
No ICE; fatigue dismissed or attributed to stress without exploration; cancer fear not addressed; ME/CFS not validated; no empathy; no shared decision making
Global Skills
🟒
Open question first; plain language throughout; red flag screen by 7 min; PHQ-9 signposted; examination communicated; summary + closing question; pacing natural
🟠
Begins with targeted questions; uses jargon without explanation; PHQ-9 not signposted; examination findings not communicated; no summary or closing question
πŸ”΄
No open question; rapid-fire targeted history; dismissive tone; no PHQ-9; no examination; no summary; patient rushed or interrupted throughout
πŸ’¬ Key Phrases β€” ICE, Diagnosis & Plan
Ideas
"What do you think might be causing this tiredness? Have you had any thoughts about what's going on?"
Concerns (cancer / lymphoma fear)
"Is there anything in particular that worries you β€” anything you were hoping I could rule out, like something more serious?"
Expectations
"What were you hoping we might be able to do today β€” a specific test, or something to help with the energy?"
Cancer fear β€” explicit reassurance
"I've specifically checked for features of lymphoma and blood cancer β€” and based on what you've told me and what I've found, I'm reassured these are not the cause."
ME/CFS β€” validation
"ME/CFS is a real, recognised medical condition. It's not 'all in your head,' and the fatigue you're experiencing is just as real as a physical injury."
Safety-net + close
"If you notice fever that won't settle, unexplained weight loss, or any new lumps before we meet again, please come back straight away β€” or call 111."
🚫 9 Danger Zones β€” Instant Deductions
βœ—
Not using PHQ-9β†’ PHQ-9 is mandatory in all fatigue presentations β€” "are you depressed?" is not equivalent
βœ—
Recommending GET for ME/CFS→ NICE NG206 (2021) explicitly removed GET from ME/CFS treatment — this is an examiner-guaranteed fail
βœ—
SSRI without 2-week safety review→ NICE NG222 mandatory; SSRIs increase energy before mood — window of highest suicide risk
βœ—
No investigation in 4-month fatigue→ Standard fatigue panel is mandatory for all unexplained fatigue >4 weeks
βœ—
Not addressing cancer fear explicitly→ Probe for it proactively — "Is there anything more serious you're worried about?" — and address it by name
βœ—
Starting levothyroxine without cortisol check if Addison's possible→ Can precipitate adrenal crisis — check cortisol first in any patient with fatigue + hyperpigmentation + postural symptoms
βœ—
Treating iron deficiency without investigating the cause→ Iron deficiency is not a diagnosis; missing GI malignancy in a patient over 50 is a serious error
βœ—
Dismissing fatigue as "stress" without organic screen→ Multiple organic causes of fatigue are easily missed; always complete standard blood panel first
βœ—
Not asking PEM in a patient with possible ME/CFS→ PEM changes management completely; missing it risks prescribing GET which worsens ME/CFS
πŸ’Š Treatment Quick-Pick by Diagnosis
Iron deficiency anaemia (ferritin <30)
β†’Ferrous sulfate 200mg TDS
With vitamin C; warn about black stools; always investigate cause; FBC at 4 weeks.
Hypothyroidism (TSH >10 mU/L)
β†’Levothyroxine 50mcg OD
25mcg if elderly or cardiac disease. TSH at 6–8 weeks. Take 30–60 min before food, away from iron/calcium/PPIs.
Depression (PHQ-9 β‰₯10) with fatigue
β†’Sertraline 50mg OD + NHS Talking Therapies
2-week mandatory review; suicide safety-net; 6-month minimum course after remission.
B12 deficiency / pernicious anaemia
β†’Hydroxocobalamin 1mg IM alt days Γ— 6
Then 3-monthly IM for pernicious anaemia (lifelong). Monitor K⁺ in first 48h of loading.
ME/CFS (PEM + unrefreshing sleep >3 months)
β†’Pacing (energy management) β€” NO GET
Specialist referral. Amitriptyline 10mg nocte if sleep disruption. Do NOT recommend GET (NICE NG206).
Type 2 diabetes (HbA1c β‰₯48 mmol/mol)
β†’Metformin 500mg OD with food; titrate
HbA1c at 3 months. B12 annually (metformin depletes B12). Lifestyle + DESMOND education programme.
β›” Never do: GET in ME/CFS | levothyroxine before cortisol check in Addison's | SSRI without 2-week review | iron without investigating cause (exclude GI malignancy) | PHQ-9 omitted in any fatigue consultation | graded exercise in PEM-positive patient
Reviewed: July 2026 Β· citations verified against current NICE / UK guidance