Endocrine · Symptom framework

Fatigue & Tiredness

NICE NG222 depression NG12 (suspected cancer pathway) NG206 ME/CFS

~25%GP consultations involve fatigue

Hb <120/130Anaemia threshold (F/M) g/L

TSH ≥10Twice, 3 months apart: consider treating subclinical (mU/L)

HbA1c ≥48Diagnose T2DM (mmol/mol)

≥3 monthsME/CFS minimum duration

PHQ-9Screen depression in all fatigue

Suspected cancer pathway referralCancer referral if red flags

PEMPost-exertional malaise: ME/CFS hallmark

📋 Clinical Stem — Fatigue & Tiredness Presentation

A patient presents with persistent tiredness or fatigue — 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 — 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 — 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 — Anaemia 28yo woman, 4-month fatigue, heavy periods, pale conjunctivae, palpitations on exertion, Hb 89 g/L, ferritin 4 μg/L. Wants to know if she needs a transfusion.

Scenario B — 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 — 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 — 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 — 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:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

▲collapse

Fatigue is one of the most diagnostically challenging presentations in primary care — 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.

🎓 Consultation opener — use existing information first

"I can see from your notes that you've come in today about feeling very tired — 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 — which in fatigue consultations is frequently an emotional agenda (depression, life crisis, fear of cancer) not the symptom itself.

1A — Start with an open question: let the patient lead, then move to targeted questions

Question to ask	Why it matters clinically	Changes what?
🟢 OPEN QUESTION — always start here"Tell me about this tiredness — 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 — 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 — 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 — even mild activity — make the fatigue significantly worse the next day or a few days later?"	Post-exertional malaise — fatigue worsening >12–48 hours after minimal physical or cognitive exertion — 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 — weight change"Have you noticed any change in your weight — either loss or gain — without trying?"	Unexplained weight loss + fatigue = malignancy, hyperthyroidism, diabetes, adrenal insufficiency, or inflammatory bowel disease until proven otherwise — 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 raise lymphoma — NICE NG12 weighs them when deciding on a suspected cancer pathway referral for unexplained lymphadenopathy or splenomegaly; persistent fatigue with pallor, fever or bruising → very urgent FBC within 48 hours. 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.	999Suspected cancer pathway referralInv
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 — 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 — 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 — Red flags: must not miss · must ask · must act

🚨

Red Flags — act before continuing history

Red flag	Why dangerous	Action
Unexplained weight loss ≥5% body weight + fatigue	Malignancy (lung, GI, haematological), severe depression, hyperthyroidism, adrenal insufficiency, or advanced HIV. Unexplained weight loss is a symptom NICE NG12 (updated April 2026) asks you to investigate for cancer.	Urgent bloods + suspected cancer pathway referral if indicated
B symptoms: fever + night sweats + weight loss	Lymphoma (Hodgkin's or non-Hodgkin's) or other haematological malignancy. Not a referral trigger alone (NICE NG12): examine for lymphadenopathy/splenomegaly; very urgent FBC within 48 hours if persistent fatigue with fever, pallor or bruising.	Very urgent FBC + examine nodes/spleen; consider suspected cancer pathway referral if unexplained lymphadenopathy
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.	Consider suspected cancer pathway referral (NICE NG12) + 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 ≥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) — 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 + haematology suspected cancer pathway referral
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 + suspected cancer pathway referral

🛡️

Safeguarding Considerations — 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

👴 Carer Burnout / Elder Neglect

Fatigue in an older patient with a dominant carer — consider exploitation or neglect
Unpaid carer (younger adult) presenting with exhaustion — carer's assessment needed
Older patient with unexplained weight loss and fatigue living with relatives — neglect screen
Patient unable to attend alone; carer answers all questions on their behalf

🧒 Children in the Household

Parent with severe depression presenting as fatigue — capacity to care for children
Child or adolescent presenting with chronic fatigue — school attendance, family dynamics
Parental alcohol or substance misuse (causing fatigue) with children at home
Adolescent with fatigue + school avoidance — 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 — concern about trafficking or labour exploitation

If a safeguarding concern is identified: See the patient alone — 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 — you do not need certainty to refer. DASH risk assessment for domestic abuse.

1C — PMH · FH · Drug history · Social history: management impact

🧬 PMH / FH — changes management

Factor	Why it matters	Management impact
Depression / anxiety (previous episodes)	Strongest single predictor of fatigue aetiology in primary care; recurrence risk high	PHQ-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 risk	TSH 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 common	Disease-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 patients	Urgent FBC; low threshold for haematology suspected cancer pathway referral
Obstructive sleep apnoea (known or suspected)	Untreated or undertreated OSA is a major and correctable cause of daytime fatigue	STOP-BANG screening; review CPAP compliance; refer back to sleep service if inadequate
Chronic kidney disease	Uraemia and renal anaemia cause severe fatigue; often undertreated	U&E + eGFR + FBC; nephrology per NG203 criteria (e.g. KFRE 5-year risk >5%, ACR ≥70, accelerated decline), if eGFR <30 and not known to nephrology (commonly used locally) or significant anaemia; erythropoietin consideration
Diabetes (T1 or T2)	Poor glycaemic control; hypoglycaemia episodes; neuropathic fatigue	HbA1c; review insulin/oral medication; check for complications; refer diabetologist if uncontrolled
Heart failure or ischaemic heart disease	Reduced cardiac output causes exertional fatigue; often attributed to age or depression	BNP; ECG; echocardiogram; cardiology review if decompensated or new-onset HF suspected

💊 Drug history · Social history — clinical impact

Factor	Why it matters	Management impact
Beta-blockers (bisoprolol, atenolol)	Fatigue is the most common and dose-dependent side effect; often attributed to the underlying condition	Review 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 fatigue	CK 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 blunting	Review timing of dose; consider switching agent; distinguish drug side effect from disease
Opioids and sedating medications	Direct cause of daytime somnolence and cognitive fatigue; commonly overlooked in chronic pain patients	Review 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 depressant	AUDIT-C or CAGE; brief intervention; check B12/folate and supplement if deficient; referral if dependent
Occupational stress / shift work / caring responsibilities	Chronic sleep deprivation from shift work, night shifts, or caring for dependants is a major and underrecognised cause	Occupational 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 — mirroring organic disease	Psychological 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 adults	Monospot / EBV titres if glandular fever suspected; ME/CFS criteria if PEM present; avoid GET

1D — ICE: Ideas · Concerns · Expectations — in every consultation, not just SCA

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.

💭 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 — 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 — 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 — "Some people in your situation worry it might be something like cancer or blood disease — is that something on your mind?" — unlocks the real agenda and allows targeted reassurance.

🎯 Expectations

"What were you hoping we might be able to do today — 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 — Psychosocial context: the person behind the fatigue

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 NG206 (ME/CFS) and NICE NG222 (depression) both call for a holistic assessment that covers psychological and social as well as physical factors.

😔 Depression and Anhedonia

Depression is the most common single cause of fatigue in primary care. It commonly presents somatically — the patient leads with tiredness, not low mood. PHQ-9 ≥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 — defined as chronic workplace stress not resolved by rest — 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.

💔 Grief and Loss

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

"Have you had any significant losses or bereavements recently — 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.

🔥 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 — 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).

👶 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 — 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 — 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.

🌑 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.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Tell me about this tiredness — what's it been like for you?"

"Is there anything about this fatigue that has really worried you — anything you've been hoping I might rule out?"

"How has your mood been underneath all this — have you been feeling low or losing interest in things?"

"Have you noticed any weight loss, fever, or night sweats — 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 — investigating without diagnosing
Missing PEM question — misses ME/CFS and prescribes GET (harmful)
No red flag screen for malignancy in a patient over 50 with unexplained fatigue

🔴 Red — 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 — 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 — 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.

Step 2

Triage Engine — Emergency · Urgent · Routine

▲collapse

The vast majority of fatigue presentations are routine. However, a small number require urgent or emergency action — 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.

🔴 Emergency

999 or Same-Day Hospital

Act immediately

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

🟠 Urgent

Same-Day / 1–2 Week Assessment

Urgent referral / same-day bloods

B symptoms (fever + night sweats + weight loss)Very urgent FBC (within 48 hours); examine nodes and spleen; consider haematology suspected cancer pathway referral if unexplained lymphadenopathy or splenomegaly (NICE NG12)
Unexplained weight loss ≥5% + fatigue (age >40)NICE NG12: urgent direct-access chest X-ray (40+ with fatigue + weight loss); site-specific tests such as FIT; 60+ with >5% loss in 6 months → assess for clarifying features, then urgent investigation or suspected cancer / non-specific symptoms pathway
Suspected Addison's disease9am cortisol same day; same-day endocrinology if acute features; steroid cover if crisis risk
Moderate-severe depression (PHQ-9 ≥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)NT-proBNP: >2000 ng/L → specialist assessment + echo within 2 weeks; 400–2000 → within 6 weeks (NICE NG106)

🟢 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 (less severe, no risk)NHS Talking Therapies / guided self-help first; antidepressant if preferred or therapy unsuitable (NICE NG222); review within 2 weeks if started
Iron deficiency anaemia (confirmed, haemodynamically stable)Oral iron; investigate cause; FBC recheck at 2–4 weeks
Hypothyroidism (confirmed on TSH)Levothyroxine titration; recheck TSH at 6–8 weeks
Suspected ME/CFS (all four core symptoms ≥6 weeks; diagnose at 3 months)Targeted baseline investigations; at 3 months specialist referral; energy management (pacing); not GET

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Triage phrases that score

"There are a few features I want to make sure we pick up on — 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 ≥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"

🔴 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.

Step 3

Do I Need This Examination?

▲collapse

Examination in fatigue is targeted rather than comprehensive — 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 — this is both good practice and high-scoring SCA behaviour.

Examination	Why it matters	What finding changes management	Changes management?
General appearance: pallor, jaundice, cachexia	Pallor of conjunctivae and palmar creases indicates anaemia. Jaundice + fatigue = hepatic pathology. Cachexia = significant weight loss — malignancy, TB, or advanced systemic disease.General observation often gives the diagnosis before any targeted examination.	Pallor → FBC urgently; jaundice → LFTs + hepatitis screen; cachexia → urgent cancer workup	YES — 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 → TSH + thyroid antibodies + USS thyroid if nodular; tender → CRP + thyroid peroxidase Ab	YES — investigation pathway
Lymph node examination: cervical, axillary, inguinal, supraclavicular	Generalised lymphadenopathy with fatigue = lymphoma, EBV/CMV, HIV, or SLE until proven otherwise. Assess size, site, persistence, fixation and systemic symptoms — consistency or tenderness alone does not distinguish lymphoma from reactive nodes.Supraclavicular lymphadenopathy is always sinister — mandates urgent workup.	Unexplained generalised lymphadenopathy → FBC, LDH, ESR, HIV, monospot; consider haematology suspected cancer pathway referral (NICE NG12); supraclavicular → suspected cancer pathway referral immediately	YES — 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 → urgent FBC + monospot + haematology; hepatomegaly → LFTs + USS abdomen; mass → urgent GI suspected cancer pathway referral	YES — 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 → ECG + FBC + TSH; JVP raised + oedema → BNP + echo; postural BP drop >20mmHg → cortisol + autonomic screen	YES — 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 — performing it demonstrates examiner-level clinical reasoning.	Psychomotor retardation → severe depression; administer PHQ-9; urgent psychiatry if severe; initiate antidepressant; assess suicide risk	YES — 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 → 9am cortisol immediately; petechiae → urgent FBC + haematology; butterfly rash → ANA + anti-dsDNA	YES — 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 → STOP-BANG for OSA; low BMI + fatigue → eating disorder screen + malignancy workup	YES — investigation direction

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Examination communication that scores

"I'm going to do a brief examination — 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 — 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 — 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

🔴 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.

Step 4

Do I Need This Investigation?

▲collapse

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 — 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.

Investigation	Clinical question it answers	What 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 → treat cause + oral iron/B12/folate; WBC abnormal (very low or very high, blasts) → urgent haematology; Plt <50 → 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 ± T3.	Raised TSH + low free T4 → levothyroxine; subclinical (normal free T4): repeat in ~3 months — TSH ≥10 twice → consider treating; TSH above range but <10, under 65 with symptoms → 6-month trial; TSH <0.1 → hyperthyroidism workup; refer endocrinology if complex
HbA1c	Diabetes (≥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 ≥48 → diabetes management pathway (lifestyle; if medication needed, MR metformin + SGLT2 inhibitor — NICE NG28 2026); 42–47 → non-diabetic hyperglycaemia: NHS Diabetes Prevention Programme + annual HbA1c
Ferritin + serum iron + TIBC	Iron deficiency (low ferritin) — 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 μg/L → iron deficiency (even if Hb normal — 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 → investigate infection/inflammatory/malignant cause; ESR >100 → prompt to investigate; if myeloma plausible, SPEP + serum free light chains (urine Bence Jones only if unavailable) — ESR alone is not a referral criterion
LFTs (Liver function tests)	Hepatic disease (hepatitis B/C, MASLD, alcoholic liver disease, malignancy). Fatigue is often the presenting symptom of chronic liver disease. Raised GGT suggests alcohol use.	Raised bilirubin + raised transaminases → hepatitis screen (HBsAg, HCV Ab); isolated GGT rise → alcohol screen; ALP pattern → 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 — raised in myeloma, malignancy, and primary hyperparathyroidism.	eGFR <30 not known to nephrology → referral (commonly used locally) + review medications; adjusted calcium ≥2.6 mmol/L → repeat; PTH with a concurrent adjusted calcium if ≥2.6 twice (NICE NG132); SPEP + serum free light chains if myeloma possible; malignancy workup if PTH suppressed
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.	Total B12 <180 ng/L (<133 pmol/L) or active B12 <25 pmol/L (NICE NG239; 180–350 ng/L / 133–258 pmol/L indeterminate — consider active B12 or MMA) → treat by cause (IM hydroxocobalamin for autoimmune gastritis, malabsorption or neurological features; oral cyanocobalamin 50–150 micrograms daily for diet-related deficiency); test anti-intrinsic factor antibody first (NICE NG239); folate deficiency → folic acid supplementation + dietary advice
PHQ-9 (Patient Health Questionnaire-9)	Validated screening tool for depression severity. PHQ-9 ≥10 = moderate-severe depression. Essential in all fatigue presentations — depression is the most common aetiology and consistently missed without formal screening.	Depression confirmed → treat by severity (NICE NG222): less severe → psychological therapy first (antidepressant not routinely first-line); more severe → CBT + antidepressant; PHQ-9 ≥15 → assess suicide risk; PHQ-9 ≥20 → urgent psychiatric review; PHQ-9 <10 → NHS Talking Therapies self-referral + review

🎓 SCA Checkpoint — Step 4TasksGlobal Skills

Investigation communication that scores

"I'd like to run some blood tests to check for the most common treatable causes — 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 — 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 — 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 — asking "are you depressed?" is not equivalent
Ordering a full autoimmune screen (ANA, ANCA, RF) without clinical indication

🔴 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; coeliac serology, HIV, cortisol or EBV serology only where the history supports them); patient understands the purpose of each test.

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

▲collapse

Communicating a fatigue diagnosis requires particular skill. Many patients present having been told "everything is normal" for years — 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 — patients frequently describe it as the first time they felt believed.

🗣️ Explaining the Diagnosis in Plain Language — say something like this

"What your blood tests are showing is that your thyroid gland — which is like the engine regulator of your body — 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 — 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 — anaemia, depression, diabetes, or ME/CFS — using a body analogy appropriate to that condition.]

💬 Addressing the patient's own explanation — why it may not be the full picture

"I just think I'm anaemic — can I have an iron injection?"
"I completely understand why you're thinking along those lines — 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 — 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 — 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 — Diagnosable and Manageable in Primary Care

GP can diagnose and treat

Iron deficiency anaemia — Hb low + ferritin <30 μg/L; treat cause + oral iron; FBC at 4 weeks.

Hypothyroidism — raised TSH with low free T4 → levothyroxine; subclinical: TSH ≥10 twice → consider treating, <10 with symptoms under 65 → 6-month trial; recheck TSH at 6–8 weeks.

Depression — treat by severity (NICE NG222): psychological therapy first in less severe; CBT + SSRI in more severe; review within 2 weeks of an antidepressant; PHQ-9 monitoring.

Type 2 diabetes — HbA1c ≥48 mmol/mol; lifestyle ± MR metformin + SGLT2 inhibitor (NICE NG28 2026); diabetes pathway.

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

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

B — Suspected — Shared Care / Specialist Input

Initiate in GP, refer for confirmation

ME/CFS (Myalgic Encephalomyelitis / CFS)

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

Obstructive Sleep Apnoea

2 or more OSAHS features (snoring, witnessed apnoeas, unrefreshing sleep, sleepiness — NICE NG202) → sleep service referral; Epworth not used alone; CPAP if confirmed.

Addison's Disease

9am cortisol + ACTH stimulation test → endocrinology; hydrocortisone replacement; steroid emergency card.

C — Emergency / Urgent — Act Now

Diagnose & refer immediately

Lymphoma

B symptoms + lymphadenopathy + raised LDH → urgent haematology suspected cancer pathway referral; staging CT; PET-CT.

Leukaemia (acute)

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

Multiple Myeloma

Bone pain + fatigue + ESR >100 + hypercalcaemia + SPEP paraprotein → urgent haematology suspected cancer pathway referral; skeletal survey.

📊 Fatigue Differential — Key Discriminating Features

Diagnosis	Discriminating features	Key investigation	First-line management
Iron deficiency anaemia	Women of reproductive age; HMB; pallor; pica; Hb low with microcytic indices	FBC + ferritin + reticulocyte count	Ferrous sulfate 200mg once daily (BSG 2021; alternate days if not tolerated); treat cause; FBC at 4 weeks
Hypothyroidism	Women >40; weight gain; cold intolerance; constipation; dry skin; slowed reflexes; raised TSH	TSH (± free T4 if TSH abnormal)	Levothyroxine 1.6 micrograms/kg/day if under 65 without cardiac disease; 25–50 micrograms if 65+ or cardiac disease; titrate by TSH
Depression	Low mood + anhedonia + early morning wakening + guilt + suicidal ideation; PHQ-9 ≥10; fatigue worse in morning	PHQ-9 score	By severity (NICE NG222): psychological therapy first in less severe; CBT + SSRI (e.g. sertraline 50mg OD) in more severe; review within 2 weeks
Type 2 Diabetes	Polyuria, polydipsia, blurred vision; obesity; family history; HbA1c ≥48 mmol/mol	HbA1c (repeat if borderline)	Lifestyle; if medication needed, MR metformin + SGLT2 inhibitor (NICE NG28 2026); diabetes nurse referral
ME/CFS	Post-exertional malaise; unrefreshing sleep; cognitive dysfunction; >3 months; normal investigations; worsens with activity	Exclusion of organic causes (full fatigue panel)	Pacing / energy management; specialist ME/CFS referral; NOT graded exercise therapy
Obstructive Sleep Apnoea	Obese male; loud snoring; witnessed apnoeas; daytime sleepiness; non-restorative sleep; morning headache	2 or more OSAHS features (NICE NG202) → sleep service (Epworth/STOP-Bang support, not alone)	CPAP; weight loss; ENT referral if structural cause
Lymphoma	Painless lymphadenopathy; B symptoms (fever, night sweats, weight loss); raised LDH; raised ESR; age any	FBC + LDH + ESR + haematology suspected cancer pathway referral	Urgent suspected cancer pathway referral; staging CT; haematology management

🎓 SCA Checkpoint — 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] — let me explain what that means in practical terms."

"I want to be clear about what I've ruled out — I haven't found any signs of [cancer / infection / serious blood disease], and that's very reassuring."

"The diagnosis I'm thinking of — ME/CFS — 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)

🔴 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.

Step 6

If Referral Is Needed — What the GP Does Before & During

▲collapse

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 — referral is not handover of responsibility.

Condition / Scenario	Urgency	What GP does before referral	What GP must NOT do
Suspected lymphoma (B symptoms + lymphadenopathy)	Haematology suspected cancer pathway referral	Send urgent FBC, LDH, ESR, LFTs, and CXR; inform patient sensitively that urgent investigation is needed to rule out a serious blood condition; complete suspected cancer pathway 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 suspected cancer pathway referral; 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	8–9am cortisol same day (NICE NG243): <150 nmol/L → start management and refer urgently; 150–300 → refer or short Synacthen test (repeat if 201–300); provide steroid sick day rules and emergency steroid card while awaiting review; educate on adrenal crisis signs.	Do NOT delay hydrocortisone if crisis is suspected or cortisol is <150 nmol/L — start per NICE NG243 and discuss with endocrinology; do NOT leave patient without crisis guidance; do NOT dismiss diagnosis because cortisol is borderline — refer for ACTH stimulation test.
ME/CFS (criteria met, normal investigations)	Routine — ME/CFS specialist service	Confirm diagnostic criteria (NICE NG206: PEM + unrefreshing sleep + cognitive dysfunction + ≥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) — 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 (2 or more OSAHS features — NICE NG202)	Routine — sleep medicine	STOP-BANG and Epworth Sleepiness Scale documented; advise not to drive while excessively sleepy; DVLA notification depends on severity and control (suspected/mild OSAHS with sleepiness → notify if not controlled within 3 months; confirmed moderate–severe with sleepiness → must notify; Group 2 stricter); weight loss advice; avoid alcohol; refer to sleep service (home respiratory polygraphy).	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 — 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 — NICE NG106: NT-proBNP >2000 ng/L → specialist assessment + echo within 2 weeks (400–2000 → within 6 weeks); do NOT start ACEi or beta-blocker without confirmed diagnosis and specialist guidance.

🎓 SCA Checkpoint — Step 6TasksRelating to Others

Referral communication that scores

"These blood results have shown something I want to investigate further — I'm going to refer you urgently to a specialist who can look into this properly."

"I want to be honest with you — 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)
No very urgent FBC or node examination in a patient with B symptoms (NICE NG12)
Allowing professional driver with severe OSA to continue driving without DVLA notification
Sending a patient home with active suicidal ideation without crisis team involvement

🔴 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.

Step 7

Management — Expectation · Goals · Lifestyle · Prescribing · Psychosocial · Follow-Up · Safety-Netting

▲collapse

Management of fatigue is diagnosis-specific — 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) — graded exercise therapy is no longer recommended.

7A — Address the patient's expectation first: validate → explain → negotiate

🤝

Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan

Validate — 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 — 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."

Explain — share your clinical reasoning

Explain the investigation strategy and the range of possible causes. Patients who understand why they are being tested — and what the results might mean — 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 — thyroid problems, anaemia, blood sugar — and I want to know if any of those are driving this before we look at other things."

Negotiate — offer something today

Even before results are back, there is almost always something useful to offer — 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 — which I'd like you to come back to discuss in two to three weeks — 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 — Why treatment matters: goals tailored to this patient

Treatment goals — 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 — tailored to the patient

"If this turns out to be your thyroid — and that's one of the things I'm looking for — 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 — because in my experience, when we approach fatigue this carefully, we almost always find something we can actually do something about."

7C — 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 — 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 — 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 — staying within the available energy envelope — 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 recommends energy management: staying within the energy limit rather than pushing through symptoms.

Energy management within the energy limit is recommended in NICE 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 — 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 spread over 3+ days

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 — Prescribing guide: what to start, in what order, and why

Treatment of fatigue is cause-specific — 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 — there is no disease-modifying drug. For OSA, CPAP is the treatment.

Iron Deficiency — Oral Iron Replacement

Ferrous sulfate 200mg once daily (BSG 2021; alternate-day dosing if not tolerated; or ferrous fumarate 210mg once daily) — take on an empty stomach if tolerated (with food if needed for adherence); vitamin C supplementation is not routinely required.

Continue for 3 months after Hb normalises to replete stores
FBC recheck at 2–4 weeks — Hb should rise by ≥10 g/L by 4 weeks; 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 → admit for transfusion assessment

Hypothyroidism — Levothyroxine

Levothyroxine 1.6 micrograms/kg/day if under 65 without cardiac disease (25–50 micrograms if 65+, cardiac disease or severe longstanding hypothyroidism) — take 30–60 min before food, away from calcium/iron/PPI.

Recheck TSH at 6–8 weeks; aim for TSH within the reference range (NICE NG145)
Titrate in 25mcg increments; review at each increment
Hashimoto's: anti-TPO antibodies positive; follow TSH annually even if euthyroid
Subclinical hypothyroidism (normal free T4): TSH ≥10 twice, 3 months apart → consider treating; above range but <10, under 65 with symptoms → 6-month trial; pregnancy/preconception → specialist thresholds

⚠ Do NOT start at full dose in elderly — risk of precipitating AF or angina

Depression — SSRI + NHS Talking Therapies

Sertraline 50mg OD (NICE NG222 advises an SSRI when an antidepressant is chosen; sertraline is often preferred in cardiac disease and for drug interactions) — take in the morning; onset 2–4 weeks.

In more severe depression, combine with CBT (NICE NG222); in less severe depression antidepressant monotherapy is not routinely first-line
Review at 2 weeks (tolerability, suicide risk), then 4–6 weeks (response)
If no response at 4–6 weeks at 50mg → increase to 100mg; if still no response → switch class
Continue for minimum 6 months after remission to prevent relapse

⚠ Review suicide risk at 2-week appointment — SSRIs increase energy before mood lifts, transiently increasing risk

B12 / Folate Deficiency + Diabetes + Addison's

B12 deficiency: Hydroxocobalamin (SPC): no neurological involvement — 1mg IM three times a week for 2 weeks, then every 2–3 months; neurological involvement — 1mg on alternate days until no further improvement, then every 2 months; dietary deficiency → cyanocobalamin oral tablets
Folate deficiency: Folic acid 5mg OD for 4 months; investigate malabsorption; dietary advice
Type 2 diabetes: If medication needed, MR metformin + SGLT2 inhibitor dual first-line (NICE NG28 2026) — metformin MR 500mg OD with food, titrated; refer to diabetes structured education programme (DESMOND)
Addison's disease: Hydrocortisone 10mg morning + 5mg lunchtime (endocrinology prescribed); fludrocortisone; sick day rules; steroid emergency card — medic-alert bracelet

ME/CFS and OSA — Non-pharmacological primary treatments

ME/CFS: Pacing (energy management) — 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 — 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) — first-line; weight loss; positional therapy; mandibular advancement splint if CPAP declined or not tolerated (NICE NG202)
DVLA for OSA: Do not drive while excessively sleepy; notify DVLA if confirmed moderate–severe OSAHS with excessive sleepiness, or suspected/mild OSAHS with sleepiness not controlled within 3 months; Group 2 licences (HGV/bus) — stricter rules apply

7E — Medication options — guideline summary (no patient selection)

Situations this summary covers

Iron deficiency anaemia
Hypothyroidism (TSH elevated)
Depression (PHQ-9 ≥10)
B12 / folate deficiency
Type 2 diabetes (HbA1c ≥48)
ME/CFS (PEM + normal bloods)
Obstructive sleep apnoea
Addison's disease
Medication side effect (beta-blocker/statin)

What the guidance says

Use the drug reference cards below for choice, cautions and monitoring for each situation listed. Check doses in the SPC.

Guideline summary — each situation is shown with what the guidance says for it, as written. Nothing is selected or worked out for an individual patient. Check doses in the current SPC and local formulary.

7F — Drug reference cards: treatment of the most common causes of fatigue

Ferrous Sulfate (Iron)

Ferrous sulfate · Ferrous fumarate · Ferrous gluconate

✓ Recommended

First-line 200mg once daily (BSG 2021)

✓ Prefer when

Confirmed iron deficiency (ferritin <30 μg/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)

✗ Avoid if

Haemochromatosis or haemolytic anaemia — iron overload risk

Concurrent antacid or PPI use — markedly reduces absorption; separate by 2 hours

Inflammatory anaemia (anaemia of chronic disease) — iron supplementation alone is ineffective; treat underlying condition

⚠ Side effects

GI intolerance (nausea, constipation, diarrhoea) — very common; take with food if needed despite reduced absorption

Black stools — warn the patient explicitly (this is expected, not GI bleeding)

Teeth staining with liquid preparations — use straw

🔬 Monitor

FBC at 2–4 weeks — Hb should rise ≥10 g/L by 4 weeks; ferritin selectively if response incomplete (no universal target)

If inadequate response: check compliance, absorption (coeliac screen), and ongoing blood loss

💬 Counselling

"Take this on an empty stomach with a glass of orange juice if you can tolerate it — the vitamin C helps your body absorb the iron. Your stools will turn black — 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 — 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 · Eltroxin · Accord brand

✓ Recommended

First-line 1.6 micrograms/kg/day (25–50 micrograms if 65+ or cardiac)

✓ Prefer when

Overt hypothyroidism (raised TSH, low free T4); subclinical with TSH ≥10 on two tests 3 months apart → consider treating

TSH above range but <10, under 65 with symptoms → 6-month trial; pregnancy/preconception → specialist thresholds

Aged 65+ or asymptomatic with TSH 4–10 → usually monitor rather than treat (individualise)

Hashimoto's thyroiditis with raised TSH and positive anti-TPO antibodies

✗ Avoid if

Untreated adrenal insufficiency — levothyroxine can precipitate adrenal crisis; treat with hydrocortisone first

Uncontrolled AF or recent MI — start at 25mcg with cardiologist input; titrate very slowly

⚠ Side effects

Overdose effects: palpitations, tremor, weight loss, sweating, AF — check TSH if these develop

Insomnia if taken in the evening — always take in the morning

Drug interactions: calcium, iron, PPIs, cholestyramine all reduce absorption — take 30–60 min before food

🔬 Monitor

TSH from about 6 weeks after initiation or dose change; about every 3 months until stable, then annually (NICE NG145)

Target: TSH within the reference range (NICE NG145)

Free T4 if TSH suppressed (to distinguish adequate replacement from hyperthyroidism)

💬 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 — 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 · Citalopram · Fluoxetine · Escitalopram

✓ Recommended

First-line Sertraline 50mg OD

✓ Prefer when

More severe depression (with CBT), or less severe where preferred or psychological therapy unsuitable or unhelpful (NICE NG222)

Sertraline: first-line in cardiac disease, safest drug interaction profile

Mirtazapine: if significant insomnia or anorexia (sedating, appetite-stimulating)

Offer NHS Talking Therapies alongside — CBT + antidepressant is preferred in more severe depression

✗ Avoid if

MAOI within 14 days (serotonin syndrome)

Do NOT use in ME/CFS as primary treatment for fatigue — SSRIs do not treat ME/CFS and may worsen symptoms

Pregnancy (consult prescribing team — 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 — must taper when stopping; do not stop abruptly

🔬 Monitor

2-week review: tolerability, suicide risk (SSRIs increase energy before mood — transient risk)

4–6 week review: PHQ-9 response; if <50% improvement → increase dose or switch agent

6-month minimum continuation after remission to prevent relapse

💬 Counselling

"This medication takes 2–4 weeks to start working — 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 — 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 · Cyanocobalamin oral

✓ Recommended

First-line 1mg IM 3×/week for 2 weeks, then every 2–3 months (SPC; no neurological involvement)

✓ Prefer when

Confirmed B12 deficiency (total B12 <180 ng/L [<133 pmol/L] or active B12 <25 pmol/L; NICE NG239) with neurological features — IM injection mandatory

Pernicious anaemia (positive intrinsic factor antibodies) — lifelong IM maintenance

Vegans/vegetarians without neurological features — oral cyanocobalamin 50–150 micrograms daily (diet-related deficiency, SPC)

Metformin-related B12 deficiency — MHRA (June 2022): check B12 if deficiency is suspected and consider periodic monitoring in those with risk factors

✗ Avoid if

Polycythaemia or Leber's optic neuropathy — hydroxocobalamin still used but with caution; specialist input

⚠ Side effects

Injection site reactions (pain, redness) — rotate sites

Acne — can occur with B12 loading doses; usually self-limiting

Allergic reactions (rare) — have resuscitation facilities available for first injection

🔬 Monitor

FBC/reticulocytes at ~1–2 weeks; clinical review at ~3 months (NICE NG239) — MCV normalises over 2–3 months

Potassium only in severe megaloblastic anaemia, cardiac disease or inpatient treatment (hypokalaemia risk as marrow recovers)

Pernicious anaemia: lifelong IM injections every 2–3 months; annual B12 level not needed once on maintenance

💬 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 2 to 3 months for life — 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 — 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 · Glucophage · Sukkarto SR

✓ Recommended

First-line 500mg OD with food; titrate

✓ Prefer when

HbA1c ≥48 mmol/mol with fatigue as presenting symptom

Obesity + insulin resistance — metformin reduces hepatic glucose output and improves insulin sensitivity

Combination with lifestyle intervention (weight loss, dietary change) — synergistic effect

CV risk reduction — metformin has cardiovascular protection beyond glucose lowering (UKPDS data)

✗ Avoid if

eGFR <30 — increased lactic acidosis risk; hold at eGFR <45 if contrast media being given

Severe liver disease or alcohol excess — impairs lactate clearance

Hospitalisation or major surgery — hold peri-operatively; restart when eating and drinking

⚠ Side effects

GI intolerance (nausea, diarrhoea) — very common; take with food; SR formulation reduces GI side effects

B12 deficiency with long-term use — check B12 if symptoms of deficiency (e.g. neuropathy, anaemia); consider periodic monitoring if risk factors (e.g. higher dose, longer duration, low-normal baseline) (MHRA 2022)

Metallic taste — common but usually transient

🔬 Monitor

HbA1c at 3 months (confirm glucose lowering), then every 3–6 months until stable

eGFR annually (or more frequently if CKD) — dose adjust at eGFR <45

B12 if symptoms of deficiency (e.g. neuropathy, macrocytic anaemia); consider periodic monitoring if risk factors (e.g. higher dose, longer duration, low-normal baseline)

💬 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 — 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 — MHRA (June 2022): test if symptoms suggest deficiency and consider periodic B12 monitoring in patients with risk factors. This is a commonly missed monitoring requirement in SCA and real-world practice alike.

Amitriptyline (sleep in ME/CFS)

Low-dose supportive — NOT antidepressant dose

✓ Recommended

Supportive 10–25mg nocte

✓ 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 — evidence for symptomatic benefit

Chronic fatigue with insomnia not responding to sleep hygiene alone

✗ Avoid if

Recent MI or significant QTc prolongation — cardiac risk

Acute closed-angle glaucoma

Elderly (falls, anticholinergic burden, confusion) — 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 — anticholinergic effects

Weight gain with prolonged use

🔬 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

💬 Counselling

"This is at a very low dose — 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 — Psychosocial impact of the diagnosis: relationships, work, identity & daily life

🤝

Living with Fatigue — 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 — 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.

💼

Work and Occupational Function

Fatigue significantly impairs work performance — 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 — 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 — GP letters of support may be needed.

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

🚗

Driving and Transport

Anyone excessively sleepy must not drive until sleepiness is controlled. DVLA notification depends on severity and control: confirmed moderate–severe OSAHS with excessive sleepiness must be notified; suspected or mild OSAHS with sleepiness if not controlled within 3 months; Group 2 rules are stricter. This is a legal obligation and must be communicated clearly.

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

Medications causing sedation (opioids, amitriptyline, sedating antihistamines) impair driving — 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 — this is a legal requirement, not just advice."

💑

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 — gentle activity groups, peer support for ME/CFS — can reduce isolation without triggering PEM.

Family members may dismiss ME/CFS as "laziness" — 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 — it might be worth thinking about how we support the whole picture."

🧠

Cognitive Function ("Brain Fog")

Cognitive dysfunction (brain fog) — impaired memory, concentration, and word-finding — 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 — 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."

🛡️

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 — 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 — 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 — 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 — "this is a real, recognised medical condition" — 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 — let's focus on what we can actually do to help."

7H — Follow-up schedule

2–3 weeks — 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

4–6 weeks — Treatment response review

Assess response to initiated treatment (iron, levothyroxine, sertraline). PHQ-9 if depression diagnosed. Side effect review for new medications. SSRI — mandatory 2-week and 4–6-week reviews (NICE NG222). Iron — FBC re-check at 2–4 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 months — 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 + ≥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

6 months — 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

Annual — Long-term fatigue and chronic disease review

Annual structured review: thyroid function (levothyroxine patients); HbA1c (diabetes); FBC + ferritin (iron deficiency); B12 (pernicious anaemia maintenance injections; metformin: if symptoms of deficiency, or periodically if risk factors such as higher dose, longer duration or low-normal baseline); PHQ-9; functional status; medication review; social prescribing update; ME/CFS progress and NICE NG206 compliance check.

Annual bloods panelPHQ-9Medication review

7I — Monitoring: cause-specific targets and review intervals

Memory rule — Fatigue Monitoring: TRIBES

Thyroid (TSH at 6–8 weeks, annually) · Reticulocyte/FBC response (2–4 weeks for iron; ~1–2 weeks FBC and ~3-month review for B12) · Insulin / HbA1c (3-monthly until stable) · B12 (2–3-monthly IM injections for pernicious anaemia; metformin users if symptoms of deficiency, or periodically if risk factors) · Energy management (ME/CFS pacing review at 3 months) · Suicide / PHQ-9 (2-week SSRI review; PHQ-9 at every depression contact)

Treatment	Test	Timing	Action threshold
Ferrous sulfate (iron)	FBC + ferritin	2–4 weeks; ferritin selectively	Hb rise <10 g/L at 4 weeks → check compliance, malabsorption, ongoing blood loss; continue iron ~3 months after Hb normalises
Levothyroxine (hypothyroidism)	TSH (± free T4)	From about 6 weeks after initiation or dose change; about every 3 months until stable, then annually	TSH above reference range → increase dose by 25mcg; TSH <0.1 → reduce dose; free T4 if TSH suppressed
Sertraline / SSRI (depression)	PHQ-9 + clinical assessment	2 weeks (mandatory safety review); 4–6 weeks (response); 3-monthly during treatment	PHQ-9 no improvement at 6 weeks at therapeutic dose → increase dose or switch agent; PHQ-9 item 9 positive (suicidal ideation) → crisis assessment same day
Hydroxocobalamin (B12 deficiency)	FBC + clinical review (serum B12 not routinely useful)	FBC/reticulocytes ~1–2 weeks; review ~3 months (NICE NG239); K⁺ only if severe anaemia/cardiac disease	Poor FBC or symptom response → re-check diagnosis; hypokalaemia in severe cases → correct per acute-care protocol
Metformin (T2DM)	HbA1c + eGFR + B12	HbA1c: 3-monthly until stable; eGFR: annually; B12: if symptoms of deficiency; periodically if risk factors (higher dose, longer duration, low-normal baseline)	HbA1c >58 at 3 months → escalate treatment (add the SGLT2i if not already on one — dual first-line under NICE NG28, Feb 2026 — or a DPP-4i); eGFR <45 → reduce dose; B12 low → supplementation

Condition / patient group	Target	Review interval
Hypothyroidism on levothyroxine	TSH within reference range (NICE NG145)	From about 6 weeks after dose change; about every 3 months until stable, then annually
Iron deficiency anaemia	Hb >120 (F) / 130 (M) g/L; no universal ferritin target	2–4 weeks (FBC); ferritin selectively; 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 diabetes	HbA1c ≤48 mmol/mol (individualised)	3-monthly until stable; 6-monthly when controlled
Pernicious anaemia (B12)	Symptom and FBC response — serum B12 not routinely re-tested once on treatment (NICE NG239)	IM hydroxocobalamin injections every 2–3 months — lifelong
ME/CFS (functional status)	Energy envelope stable; PEM not triggered	3-monthly specialist reviews; annual GP structured review

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

Medico-legal protection: documented safety-net demonstrates you considered malignancy in a fatigue presentation

NICE NG222 SSRI mandatory review: 2-week review after initiation is a guideline standard — failure to arrange or safety-net is a governance breach

ME/CFS — prevents "diagnostic overshadowing" where new pathology is attributed to ME/CFS without investigation

Empowers the patient to seek the right level of care without unnecessary emergency attendance

Reduces re-consultation for non-urgent symptom escalation by establishing clear criteria

GMC Good Medical Practice: patients must be given information to recognise deterioration and know how to seek help

2–3 weeks: Blood results review; PHQ-9 if not done; start treatment if organic cause found

2 weeks (SSRI): Review per NICE NG222 (1 week if 18–25 or at increased suicide risk) — tolerability + suicide risk assessment

Urgent / A&E: New B symptoms; active suicidal ideation; Addisonian crisis features

🎓 SCA Checkpoint — 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 — 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 — and if at any point you feel like harming yourself, please contact us the same day."

"Before you go — is there anything we haven't covered, or anything else on your mind?"

Deductions — 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 — 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 — full criteria

ICE fully explored — cancer fear, expectation for investigations, illness model
Fatigue validated as real and taken seriously — not dismissed as "stress"
ME/CFS: diagnosis acknowledged as real medical condition, not psychiatric
Patient's expectation negotiated — investigation plan agreed, not imposed
Depression discussed empathetically — stigma addressed if raised
Closing question asked — "anything else on your mind?"

🔴 Red — 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 — 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 — 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.

"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 — 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 — 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 — 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 — wakes up exhausted even after 8 hours
Periods: regular, moderately heavy (4–5 days, changing pad 4× daily on heaviest day)
No weight loss — if anything, gained 2–3 kg from inactivity
No fever, no night sweats, no lumps
Concentration: significantly impaired — "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 — I used to love running, haven't done it in months"
No PEM — activity doesn't specifically worsen fatigue the next day beyond general tiredness

Lifestyle + bonus details

Diet: poor — 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 — that's actually part of why I'm here today, if I'm honest."

"Look — 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 — 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.

🏥

Clinic Quick Reference

Fatigue & Tiredness — Clinical Decision Framework

NICE NG206 (ME/CFS) · NICE NG222 (Depression) · Multiple guidelines

▼expand

🚦 1 — Triage System

Patient presents with fatigue → red flag screen first: B symptoms? Weight loss? Suicidal ideation?

↓

🔴 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 — 24–72 hours

B symptoms (fever + night sweats + weight loss) → very urgent FBC + node/spleen examination; consider suspected cancer pathway referral if unexplained lymphadenopathy (NICE NG12)
Unexplained weight loss ≥5% + fatigue (age >40)
Suspected Addison's (postural dizziness + hyperpigmentation)
PHQ-9 ≥15 with safeguarding concern / suicidal ideation
New heart failure suspected (fatigue + BNP elevated)

Same-day bloods + urgent referral

🟢 Routine — primary care

Fatigue >4 weeks, no red flags → standard fatigue panel + PHQ-9
Depression (less severe, no risk) → NHS Talking Therapies first; SSRI if preferred or therapy unsuitable (NICE NG222)
Iron deficiency / hypothyroidism confirmed → treat and review
ME/CFS suspected → pacing + specialist referral

Standard fatigue panel + review 2–3 weeks

🔬 2 — Diagnostic Pathway

Targeted Fatigue Blood Panel (guided by history and examination)

✓ FBC (anaemia, leukaemia, thrombocytopaenia)

✓ TSH (hypothyroidism / hyperthyroidism)

✓ HbA1c (diabetes)

✓ Ferritin + serum iron (iron deficiency — especially women)

✓ CRP + ESR (if inflammatory or infective disease is plausible)

✓ LFTs (hepatic disease, alcohol, malignancy)

✓ U&E + eGFR + calcium (renal disease, Addison's, myeloma)

✓ B12 + folate (if indicated — macrocytosis, diet, malabsorption, neurological symptoms)

✓ PHQ-9 (depression — mandatory validated tool, not clinical impression)

Additional Investigations — 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 + serum free light chains: bone pain, hypercalcaemia or very high ESR where myeloma is plausible → myeloma screen (urine BJP if FLC unavailable)

ANA + anti-dsDNA: Butterfly rash, joint pain, thrombocytopaenia → SLE screen

PSA: Only with prostate symptoms or NG12 criteria — not for fatigue alone

STOP-BANG + Epworth: Snoring, witnessed apnoeas, obese → OSA screen

LDH: B symptoms + lymphadenopathy → lymphoma screen

📊 3 — Key Numbers

PHQ-9 ≥10

Moderate depression — treat actively

Hb <120/130

Anaemia threshold F/M (g/L)

TSH ≥10

Twice, 3 months apart: consider treating subclinical hypothyroidism (mU/L)

HbA1c ≥48

Diagnose T2DM (mmol/mol)

Ferritin <30

Iron deficiency even with normal Hb (μg/L)

B12 <180 ng/L

Total B12 deficiency (= <133 pmol/L; active B12 <25 pmol/L; NICE NG239) — treat by cause (IM or oral)

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

2+ features

Suspect OSAHS → sleep service (NICE NG202; not Epworth alone)

PEM

Post-exertional malaise = ME/CFS hallmark; GET contra-indicated

💊 4 — Medication Decision & Choice

Cause-Specific Treatment Algorithm

Iron deficiency: Ferrous sulfate 200mg once daily (BSG 2021); FBC at 2–4 weeks; treat cause (HMB, coeliac)

Hypothyroidism: Levothyroxine 1.6 micrograms/kg/day (25–50 micrograms if 65+ or cardiac disease); TSH at 6–8 weeks; target TSH within reference range (NG145)

Depression: By severity (NICE NG222) — Talking Therapies first in less severe; sertraline 50mg OD + CBT in more severe; 2-week review; 6-month minimum course

B12 deficiency: Hydroxocobalamin 1mg IM 3×/week for 2 weeks, then every 2–3 months (SPC); neurological involvement: alternate days until no further improvement, then every 2 months

T2DM: MR metformin + SGLT2 inhibitor if medication needed (NICE NG28 2026); HbA1c at 3 months; B12 if symptoms of deficiency; periodic monitoring if risk factors

ME/CFS: NO pharmacological first-line treatment; pacing; specialist referral; sleep support (amitriptyline 10mg nocte if needed)

Important Prescribing Rules — Fatigue

⛔ Do NOT start levothyroxine without excluding adrenal insufficiency first (risk of adrenal crisis)

⛔ Do NOT recommend graded exercise therapy (GET) in ME/CFS — NICE NG206 explicitly contra-indicated

⛔ Do NOT give iron without investigating the cause — iron deficiency is not a diagnosis in itself

⛔ Do NOT prescribe SSRI without arranging 2-week review and giving suicide safety-net

✅ B12 testing on metformin if deficiency suspected; periodic monitoring if risk factors (MHRA 2022)

✅ Levothyroxine away from iron, calcium, PPIs (take 30–60 min before food)

⚠ 5 — Safety Netting & Follow-Up

Follow-up timeline

2 weeks (SSRI): Mandatory safety review — tolerability + suicide risk

2–3 weeks: Blood results review; start treatment; PHQ-9 review

4–6 weeks: Treatment response (FBC/TSH re-check; PHQ-9 response)

3 months: ME/CFS criteria assessment; medication review; specialist referral

Annual: Thyroid / HbA1c / B12 / FBC / PHQ-9 structured review

📌 SSRI 2-week review is NICE NG222 mandatory — cannot be omitted

🔬 6 — Monitoring & Red Flags

Treatment	Test	Timing	Action threshold
Ferrous sulfate	FBC + ferritin	2–4 weeks; ferritin at 3 months	Hb rise <10 g/L → check compliance, cause, malabsorption
Levothyroxine	TSH (± free T4)	6–8 weeks; annually stable	TSH above reference range → increase dose; TSH <0.1 → reduce dose
Sertraline / SSRI	PHQ-9 + clinical review	2 weeks (mandatory); 4–6 weeks	PHQ-9 item 9 positive → crisis assessment same day; no response at 6 weeks → dose increase or switch
Metformin	HbA1c + eGFR + B12	HbA1c: 3-monthly; eGFR: annually; B12 if symptoms of deficiency; periodic monitoring if risk factors	eGFR <45 → reduce dose; B12 low → supplement
Hydroxocobalamin (IM)	FBC + clinical review	~3 months (NICE NG239); FBC ~1–2 weeks	No FBC response → re-check diagnosis; K⁺ only if severe anaemia
PHQ-9 monitoring (depression)	PHQ-9	Every GP contact during depression treatment	PHQ-9 ≥15 → assess suicide risk; <5 = remission

🚨 Red flags — urgent action: B symptoms (fever + night sweats + weight loss); lymphadenopathy; unexplained weight loss >5%; active suicidal ideation; adrenal crisis features; FBC with blast cells

🛡️ 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

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Consultation Flow — with Domain Scoring

0–2 min

Open & Red Flag Screen

"Tell me about this tiredness — what's it been like for you?"

Use case card info as your opener — 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

✗ Re-asking documented info · ✗ No red flag screen · ✗ 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 — anything you've been hoping I could rule out?"

Cancer fear is the most common hidden concern. Probe for it directly — do not wait for the challenge.

Ask PEM specifically: "Does activity make the fatigue significantly worse the following day?" — changes management completely.

Tasks Relating to Others

✗ No cancer fear probe · ✗ PEM not asked · ✗ ICE missed entirely · ✗ No mood screen

5–7 min

PHQ-9 + Examination

"I'd like you to complete this questionnaire about your mood — 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 — it is a Task, not just nice to have.

Tasks Global Skills

✗ No PHQ-9 · ✗ Examination not signposted · ✗ Findings not communicated · ✗ 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] — and I want to run tests to confirm. Importantly, I'm not finding features of [cancer / something more sinister]."

Explicitly address the cancer fear — don't assume the patient is reassured by a "normal examination." They need to hear it said.

Tasks Relating to Others

✗ Not addressing cancer fear · ✗ Recommending GET if PEM positive · ✗ 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 — 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

✗ No safety-net for B symptoms · ✗ SSRI without suicide safety-net · ✗ No follow-up · ✗ No closing question

🔴🟠🟢 RAG Scoring — 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

🔴

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

🔴

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

🔴

No open question; rapid-fire targeted history; dismissive tone; no PHQ-9; no examination; no summary; patient rushed or interrupted throughout

💬 Key Phrases — 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 — anything you were hoping I could rule out, like something more serious?"

Expectations

"What were you hoping we might be able to do today — a specific test, or something to help with the energy?"

Cancer fear — explicit reassurance

"I've specifically checked for features of lymphoma and blood cancer — and based on what you've told me and what I've found, I'm reassured these are not the cause."

ME/CFS — 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 — or call 111."

🚫 9 Danger Zones — Instant Deductions

✗

Not using PHQ-9→ PHQ-9 is mandatory in all fatigue presentations — "are you depressed?" is not equivalent

✗

Recommending GET for ME/CFS→ NICE NG206 (2021) explicitly removed GET from ME/CFS treatment — this is an examiner-guaranteed fail

✗

SSRI without 2-week safety review→ NICE NG222 mandatory; SSRIs increase energy before mood — window of highest suicide risk

✗

No investigation in 4-month fatigue→ Standard fatigue panel is mandatory for all unexplained fatigue >4 weeks

✗

Not addressing cancer fear explicitly→ Probe for it proactively — "Is there anything more serious you're worried about?" — and address it by name

✗

Starting levothyroxine without cortisol check if Addison's possible→ Can precipitate adrenal crisis — check cortisol first in any patient with fatigue + hyperpigmentation + postural symptoms

✗

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

✗

Dismissing fatigue as "stress" without organic screen→ Multiple organic causes of fatigue are easily missed; always complete standard blood panel first

✗

Not asking PEM in a patient with possible ME/CFS→ PEM changes management completely; missing it risks prescribing GET which worsens ME/CFS

💊 Treatment Quick-Pick by Diagnosis

Iron deficiency anaemia (ferritin <30)

→Ferrous sulfate 200mg once daily

Warn about black stools; always investigate cause; FBC at 2–4 weeks.

Hypothyroidism (overt, or subclinical meeting NG145 criteria)

→Levothyroxine 1.6 micrograms/kg/day

25–50 micrograms if 65+ or cardiac disease. TSH at 6–8 weeks. Take 30–60 min before food, away from iron/calcium/PPIs.

Depression (more severe, or less severe if preferred) with fatigue

→Sertraline 50mg OD + NHS Talking Therapies

2-week mandatory review; suicide safety-net; 6-month minimum course after remission.

B12 deficiency / pernicious anaemia

→Hydroxocobalamin 1mg IM 3×/week for 2 weeks

Then every 2–3 months (lifelong in pernicious anaemia); neurological involvement: alternate days until no further improvement, then every 2 months (SPC). Review at ~3 months (NICE NG239).

ME/CFS (PEM + unrefreshing sleep >3 months)

→Pacing (energy management) — NO GET

Specialist referral. Amitriptyline 10mg nocte if sleep disruption. Do NOT recommend GET (NICE NG206).

Type 2 diabetes (HbA1c ≥48 mmol/mol)

→Metformin 500mg OD with food; titrate

Add an SGLT2 inhibitor (NICE NG28 2026 dual first-line). HbA1c at 3 months. B12 if symptoms of deficiency; periodic monitoring if risk factors. Lifestyle + DESMOND education programme.

Fatigue & Tiredness · GP Clinical Reasoning Framework v2 · NICE NG206 ME/CFS (2021) · NICE NG222 Depression (2022, updated December 2025) · NICE NG28 T2DM (2015, updated) · NICE NG106 Heart Failure (2018) · NICE NG12 Suspected cancer (updated April 2026) · NICE NG145 Thyroid disease (2019) · BSG iron deficiency anaemia guideline (2021) · NICE NG239 Vitamin B12 deficiency in over 16s (2024) · MHRA Drug Safety Update (June 2022, metformin and B12)

v3: Dual tailored summaries (Clinic + SCA) with visual algorithms · v2: Clinical stem · Open Q first · ICE in all modes · Psychosocial yellow flags (1E + 7G) · Lay language DDx (Step 5) · Safeguarding (Step 1) · Expectation management (7A) · SCA RAG checkpoints after every step · SCA Scorecard as standalone section

Teaching clinicians why each step matters — not just what to do · Always consult current SPC · Clinical judgement takes precedence over any framework · NICE NG206 (2021): GET is no longer recommended for ME/CFS — pacing is first-line

Fatigue & Tiredness

Red Flags — act before continuing history

Safeguarding Considerations — Consider in Every Consultation

🏠 Domestic Abuse / Coercive Control

👴 Carer Burnout / Elder Neglect

🧒 Children in the Household

⚠ Modern Slavery / Exploitation

😔 Depression and Anhedonia

😰 Anxiety and Chronic Stress

💔 Grief and Loss

🔥 Occupational Burnout

👶 Caring Responsibilities and Isolation

🌑 Social Isolation and Meaning

999 or Same-Day Hospital

Same-Day / 1–2 Week Assessment

Manage in Primary Care

ME/CFS (Myalgic Encephalomyelitis / CFS)

Obstructive Sleep Apnoea

Addison's Disease

Lymphoma

Leukaemia (acute)

Multiple Myeloma

Validate — name their expectation

Explain — share your clinical reasoning

Negotiate — offer something today

Work and Occupational Function

Driving and Transport

Relationships and Social Life

Cognitive Function ("Brain Fog")

Benefits, Financial Impact, and Legal Rights

Identity and the Illness Experience

2–3 weeks — Blood results review

4–6 weeks — Treatment response review

3 months — Chronic fatigue threshold / ME/CFS assessment

6 months — Structured chronic fatigue review

Annual — Long-term fatigue and chronic disease review

Memory rule — Fatigue Monitoring: TRIBES

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda

Symptoms if asked directly

Lifestyle + bonus details