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Table of Contents
Suggest an improvement
Taking a comprehensive tiredness history is an important skill often assessed in OSCEs. This guide provides a structured framework for taking a tiredness history in an OSCE setting.
Tiredness is a common presenting complaint. Clinicians often use the term ‘tired all the time‘ (shortened to TATT) in medical notes.
A wide range of conditions can cause tiredness. A thorough history is essential to help guide appropriate investigations and management.
A patient may complain of feeling tired when they are describing one of three groups of symptoms:
- Daytime somnolence (sleepiness): feeling they need to sleep during the day and/or falling asleep at inappropriate or inconvenient times
- Fatigue: defined as “a sensation of exhaustion during or after usual activities, or a feeling of inadequate energy to begin these activities”1
- A sensation of generalised weakness of the body and/or limbs (less common)
Some patients may have a combination of these symptoms, but determining the predominant feature will help determine the underlying cause.
Excessive somnolence most commonly results from insufficient quality and/or quantity of sleep. This may be due to a primary sleep disorder or secondary to a wide range of other conditions.
Primary sleep disorders
Primary sleep disorders include:
- Obstructive sleep apnoea: airway obstruction during sleep causes excessive snoring and apnoea, resulting in brief arousals from sleep, which can happen hundreds of times per night. The patient is usually unaware of waking up, but they report feeling unrefreshed in the morning and may wake with a headache. Bed partners are likely to be able to give a better history of snoring and apnoeic episodes than the patient.
- Restless leg syndrome: unpleasant feelings in the legs in the evenings and during the night, which improve when the legs are moved.
- Parasomnias: sleepwalking and night terrors
Other conditions and circumstances associated with poor sleep include:
- Lifestyle factors: excessive caffeine consumption, especially in the evening, can cause difficulty sleeping. Alcohol consumption results in poor quality sleep, although patients may perceive that it helps them to initiate sleep. Shift work can disrupt the circadian rhythm.
- Pain (any cause): inflammatory musculoskeletal conditions (e.g. spondyloarthropathies) are typically associated with pain and stiffness, which wakes the patient in the second half of the night.
- Lower urinary tract symptoms (LUTS): prostatic hyperplasia may result in nocturia multiple times per night.
- Parkinson’s disease: daytime somnolence may be due to the disease itself, disturbed sleep at night and/or medications used in its treatment, such as dopamine agonists.2
- Mental health problems: any condition that causes anxiety or stress may result in sleep problems, particularly difficulties initiating sleep. In depression, patients often wake early in the morning and cannot get back to sleep.
- Medications: many medications cause somnolence. Some, such as Z-drugs, benzodiazepines and certain antidepressants, are prescribed to help with sleep but can leave the patient feeling somnolent the following day. Other medications, such as opioids and first-generation antihistamines, have sleepiness as a common side effect.
Although less common, it is important to consider narcolepsy in the differential diagnosis. In this condition, patients experience a sudden onset of sleep, which they cannot prevent and which can occur when they are active (e.g. during a conversation). This distinguishes it from normal dozing, which typically occurs during passive activities, such as watching television.
Additional features of narcolepsy are cataplexy (sudden loss of muscle tone in response to triggers such as laughter and surprise), hypnagogic hallucinations (distressing hallucinations when falling asleep and/or waking up) and sleep paralysis.3
The differential diagnosis for fatigue is extremely wide-ranging. In most of these conditions, fatigue will be just one of the presenting symptoms.
- Cardiovascular: heart failure, ischaemic heart disease
- Respiratory: any condition which causes chronic shortness of breath, including chronic obstructive pulmonary disease (COPD), pulmonary fibrosis and sarcoidosis
- Gastroenterological: inflammatory bowel disease, coeliac disease, autoimmune liver disorders (e.g. primary biliary cirrhosis)
- Genitourinary: uraemia secondary to renal impairment of any cause
- Gynaecological: pregnancy, anaemia secondary to heavy menstrual bleeding of any cause, peri-menopause or menopause
- Rheumatological: systemic lupus erythematosus (SLE), inflammatory conditions (e.g. rheumatoid arthritis), chronic pain conditions (e.g. fibromyalgia)
- Neurological: brain tumours, multiple sclerosis, Parkinson’s disease
- Haematological: anaemia of any cause, as well as iron deficiency in the absence of anaemia
- Endocrine: diabetes, hypothyroidism, Addison’s disease
- Infective: fatigue is a feature of many acute infections; it has a particular association with glandular fever, Lyme disease, acute hepatitis, HIV and tuberculosis (TB). It is also important to consider long-COVID.
- Malignancy: any form of malignancy can cause fatigue, but particularly those which may present with anaemia (e.g. gastroenterological or haematological malignancies) and those which may be associated with hypercalcemia (e.g. lung, breast, renal and thyroid cancers)
- Medications: many drugs have a side effect of fatigue (e.g. beta-blockers, antidepressants and antiemetics)
- Psychological: depression and anxiety often cause fatigue, as can acute stress reactions. However, it is also important to note that fatigue can cause anxiety and depression, meaning that a psychological cause should not be diagnosed without carefully considering potential physical causes.
- Lifestyle/environmental: excessive exercise, alcohol misuse. Carbon monoxide poisoning should also be considered.
Long COVID (also called post-COVID syndrome) is an emerging condition.
NICE defines long COVID as “signs or symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis”.4 Patients may experience other symptoms besides fatigue, including cough, chest pain, breathlessness, brain fog, headache, palpitations and arthralgia.
If other causes have been excluded and the fatigue is persistent, chronic fatigue syndrome (CFS) (also known as myalgic encephalomyelitis or ME) should be considered.
CFS/ME is defined as persistent fatigue for a minimum of six weeks, which significantly impairs the ability to engage in usual activities, cannot be explained by any other condition and has all of the following:5
- Debilitating fatigue not caused by excessive physical or cognitive exertion and not significantly relieved by rest
- Post-exertional malaise, which is disproportionate to the activity
- Unrefreshing sleep and/or sleep disturbance
- Cognitive problems: word-finding difficulties, poor concentration, and short-term memory impairment
If weakness is the predominant symptom, consider:
- Neuromuscular disorders, such as motor neurone disease (MND) and myasthenia gravis
- Osteomalacia secondary to vitamin D deficiency
- Cushing’s syndrome, which causes proximal muscle weakness
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
- Demonstrating empathy in response to patient cues: both verbal and non-verbal.
- Active listening: through body language and your verbal responses to what the patient has said.
- An appropriate level of eye contact throughout the consultation.
- Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
- Making sure not to interrupt the patient throughout the consultation.
- Establishing rapport (e.g. asking the patient how they are and offering them a seat).
- Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
- Summarising at regular intervals.
Use open questioning to explore the patient’s presenting complaint:
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, can you tell me more about that?”
- “Can you describe what that tiredness is like?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
The first step is to establish whether the patient’s main symptom is daytime somnolence, fatigue, weakness, or a combination:
- “When you describe feeling tired, are you referring to feeling unusually or excessively sleepy? Or is it exhaustion or weakness, but without sleepiness?”
Further questions can help clarify which symptom the patient is experiencing.
Clarify the onset of the tiredness:
- “How long have you been feeling tired?”
- “Did it come on suddenly, or has it come on gradually?”
Sudden onset may point to an acute cause, such as an infection or a new medication.
Gradual onset is more likely seen in chronic conditions such as hypothyroidism, heart failure, liver disease or renal failure.
Ask if there are other symptoms which are associated with the tiredness:
- “Are there any other symptoms that seem associated with the tiredness?”
Given the wide differential diagnosis, there are many potential additional symptoms to consider.
It may be helpful to group them as follows:
- Cardiovascular or respiratory: chest pain, shortness of breath, leg oedema, cough
- Gastroenterological: change in bowel habit, nausea or vomiting, abdominal pain, blood loss (fresh rectal bleeding, melaena, haematemesis)
- Genitourinary: nocturia, polyuria or oliguria, haematuria
- Gynaecological: menorrhagia; menstrual irregularities, including amenorrhea
- Rheumatological: joint or back pain; joint erythema or swelling, rashes
- Neurological: headaches, vomiting, visual disturbances, sensory disturbances, limb weakness, cognitive impairment, tremors
- Haematological: anaemia may cause breathlessness; the patient or family may have noted unusual pallor.
- Endocrine: polyuria and/or polydipsia, unexplained weight changes, skin changes, symptoms of postural hypotension (seen in Addison’s disease)
- Infective: fevers, night sweats, weight loss, lymphadenopathy
- Malignancy: general symptoms, such as night sweats, weight loss, lymphadenopathy, as well as site-specific symptoms
- Psychological: it may be helpful to use the screening questions for depression (see below)
Screening questions for depression
- “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
- “During the last month, have you often been bothered by little interest or pleasure in doing things?”
If the answer to either of these is yes, explore the possibility of depression.
Clarify how the tiredness has changed over time:
- “How has the tiredness changed over time?”
- “Is it constant, or does it get better and worse?”
Tiredness caused by conditions such as renal failure, heart failure and anaemia will tend to be constant and progressively worsen over weeks to months.
The tiredness associated with depression is more likely to fluctuate, generally worse in the mornings. Long-COVID and CFS/ME are often associated with post-exertional malaise.
It is also helpful to ask if a temporal relationship exists between tiredness and the patient starting new medications.
Additional considerations for patients presenting with daytime somnolence include:
- What happens when the patient feels sleepy? Can they resist sleepiness, or do they fall asleep involuntarily? If they fall asleep involuntarily, in what sorts of situations would this happen?
- Ask the patient to describe their bedtime routine. It is helpful to establish what time they go to bed, sleep latency (how long it takes them to fall asleep) and at what time they wake up, as well as to find out if they are aware of anything disturbing their sleep.
The Epworth Sleepiness Scale is a helpful tool to assess the severity of the patient’s sleepiness.6
Red flags for tiredness
Red flag symptoms which suggest a serious or potentially life-threatening cause of tiredness include:7
- Weight loss of 5% or more over 6-12 months (malignancy, diabetes, Addison’s disease)
- Fever, night sweats, lymphadenopathy (malignancy, infection)
- Muscle or joint pain (inflammatory arthritis or connective tissue disease)
- Focal neurological symptoms suggesting brain tumour or neurodegenerative disorder
- History of tick bites may suggest Lyme disease
- Spontaneous onset of sleep when the patient is active, such as when talking or eating (narcolepsy)
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
- “What do you think the problem is?”
- “What are your thoughts about what is happening?”
- “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
- “Is there anything, in particular, that’s worrying you?”
- “What’s your number one concern regarding this problem at the moment?”
- “What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
- “What were you hoping I’d be able to do for you today?”
- “What would ideally need to happen for you to feel today’s consultation was a success?”
- “What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding which symptoms to ask about depends on the presenting complaint and your experience level. Tiredness has a broad differential diagnosis, and the systemic enquiry will vary depending on the clinical presentation. The key symptoms are listed above in the history of presenting complaint section.
Past medical history
Ask if the patient has any medical conditions:
- “Do you have any medical conditions?”
- “Are you currently seeing a doctor or specialist regularly?”
Ask if the patient has previously undergone any surgery (e.g. coronary artery bypass grafts, coronary artery stents, heart valve replacements):
- “Have you ever previously undergone any operations or procedures?”
- “When was the operation/procedure and why was it performed?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
Examples of relevant medical conditions
Medical conditions of particular relevance to tiredness include:
- Ischaemic heart disease
- Heart failure
- Respiratory disease, particularly COPD
- Chronic kidney disease
- Autoimmune or inflammatory conditions
- Haematological disorders
- Endocrine conditions, such as diabetes and thyroid dysfunction
- Infectious diseases
- Psychiatric conditions
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:
- “Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side effects from their medication:
- “Have you noticed any side effects from the medication you currently take?”
- “Do you think that your tiredness started after you began taking any of your current medications?”
Medications which commonly cause fatigue and/or excessive somnolence include:
- Hypnotics, such as Z-drugs and benzodiazepines
- Anti-depressants, particularly trazodone and mirtazapine
- First-generation antihistamines, such as chlorphenamine (Piriton)
Ask the patient if there is any family history of diseases which may be associated with tiredness (e.g.cardiovascular disease, autoimmune diseases, renal or liver impairment, neurological disorders, endocrine disorders, or malignancy):
- “Do any of your parents or siblings have any medical conditions?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors).
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:
- “I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
- “Do you remember what medical condition was felt to have caused his death?”
General social context
Explore the patient’s general social context, including:
- The impact of tiredness on the patient’s ability to function, including their ability to work and to fulfil any caring responsibilities.
- Life circumstances which may be causing particular stress (e.g. illness in the family, relationship difficulties or problems at work)
- Work patterns, in particular, whether the patient regularly works night shifts.
- Does anyone who lives in the same property as the patient have similar symptoms? If carbon monoxide poisoning is the cause, this would be likely to affect others at home.
Ask about foreign travel, as this may raise the possibility of infectious disease.
Ask about the risk of tick bites from working or walking on land grazed by livestock, or in woodland.
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:
- pack-years = [number of years smoked] x [average number of packs smoked per day]
- one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Excess use of alcohol can cause a depressed mood and a reduction in sleep quality, both of which can cause tiredness.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Ask about the patient’s current occupation:
- Explore what tasks the patient performs to identify risks posed by fatigue and sleepiness (e.g. operating heavy machinery). They may need to take a break from work until the problem has been investigated and treated.
If the patient drives and has presented with daytime somnolence, it is important to advise them not to drive until they have been fully investigated. They must inform the Driver and Vehicle Licensing Agency (DVLA) if they are diagnosed with a condition such as obstructive sleep apnoea or narcolepsy.8
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
- NICE CKS. Tiredness/fatigue in adults. Available from: [LINK]
- NICE CKS. Parkinson’s Disease. Available from: [LINK]
- Boon, NA. Colledge, NR, Walker, BR (eds). Davidson’s Principles & Practice of Medicine 20th Ed. Churchill Livingstone Elsevier, 2006
- BMJ Best Practice. Coronavirus Disease 2019 (COVID-19) Available from: [LINK]
- NICE CKS. Tiredness/fatigue in adults. Available from: [LINK]
- Epworth Sleepiness Scale. Available from: [LINK]
- NICE CKS. Tiredness/fatigue in adults. Available from: [LINK]
- DVLA. Assessing fitness to drive: a guide for medical professionals. Available from: [LINK]