Tiredness / Chronic Fatigue
Persistent, unexplained fatigue lasting six months or more that is not substantially relieved by rest and significantly impairs daily functioning.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Depression / anxiety | Low mood ≥ 2wk + anhedonia + sleep/appetite Δ | 「最近有冇覺得好低落？對嘢冇晒興趣？」 | ~30% |
| Viral / post-viral fatigue | Recent URTI, self-limiting < 6wk | 「之前有冇傷風感冒？」 | ~20% | |
| Iron deficiency anaemia (esp. menstruating ♀) | Menorrhagia/GI blood loss + pallor + microcytic indices | 「月經多唔多？有冇頭暈面青？」; conjunctival pallor | ~15% | |
| Serious Not To Miss | Diabetes mellitus | Polyuria, polydipsia, weight loss | 「有冇口渴、小便多、消瘦？」 | ~5% |
| Hypothyroidism | Cold intolerance, constipation, weight gain, bradycardia | 「有冇怕凍、便秘、肥咗？」; bradycardia, dry skin | ~5% | |
| Heart failure | SOBOE, orthopnoea, ankle oedema | 「行路有冇氣喘？腳腫？瞓平有冇唞唔到氣？」 | ~3% | |
| Malignancy (lymphoma, leukaemia, solid organ) | Weight loss + night sweats + lymphadenopathy | 「有冇消瘦？夜晚出汗？有冇摸到頸/腋下有粒嘢？」 | ~2% | |
| Chronic kidney disease | Nocturia, itch, poor appetite; Cr ↑, normocytic anaemia [4] | 「夜晚起身去廁所幾多次？有冇痕？」 | ~2% | |
| Adrenal insufficiency | Hyperpigmentation, postural hypotension, weight loss, hypoNa [5] | 「皮膚有冇深色咗？企起身有冇頭暈？」 | <1% | |
| Pitfalls | Obstructive sleep apnoea | Snoring, witnessed apnoeas, unrefreshing sleep, obesity | 「枕邊人有冇話你鼻鼾好大或者停咗呼吸？」 | ~10% |
| Chronic hepatitis B (HK-prevalent) | Known carrier, RUQ discomfort, LFT deranged | 「你有冇乙型肝炎？」 | ~3% | |
| Coeliac disease | Chronic diarrhoea, bloating, IDA despite adequate diet | 「食完嘢有冇肚脹肚瀉？」 | <1% | |
| Masquerades | Depression (masquerade #1 for fatigue) [1][3] | PHQ-2 positive | 「有冇覺得自己好無用？有冇唔想生存嘅念頭？」 | ~30% |
| Anaemia (any cause) | Pallor, SOBOE, palpitations | 「有冇心跳快？面青？」 | ~10% | |
| Diabetes / endocrine | Polyuria, polydipsia, thyroid symptoms | As above | ~5% | |
| Drugs (β-blockers, sedatives, antihistamines, statins) | Temporal link to starting medication | 「你開始食呢隻藥之後先開始攰？」 | ~5% | |
| Trying to Tell Me Something? | Work/family stress, burnout, relationship concern | Ask open-ended: "why today?" | 「其實今日點解嚟睇醫生？有冇嘢想講但唔知點開口？」 | ~25% |
| Health anxiety (fear of cancer, serious disease) | Specific fear driving visit | 「你最驚係咩病？」 | ~10% |
GC Lecture High Yield [1]: "Chronic fatigue is not normal. Differentiate between fatigue from organic disease and fatigue from anxiety/depression. Only about 15% with organic cause. Consider infectious, anaemia, endocrine, sleep disturbances, meds and malignancy. Chronic fatigue syndrome is a specific clinical diagnosis."
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, introduce self, build rapport | 「李先生/小姐你好，我係陳醫生。今日想了解下你嘅情況，方唔方便傾下？」 | Warm opening, permission-seeking → interpersonal marks |
| 0:30–1:30 | Open-ended exploration of CC + HPI | 「你話覺得好攰，可唔可以講多啲？幾時開始？攰到咩程度？影唔影響你返工/日常生活？」 | Let patient talk first; elicit duration, severity, functional impact |
| 1:30–2:30 | Focused Hx: red flags + systems review | 「有冇消瘦？夜晚出汗？發燒？有冇痕癢/面腫/怕凍？大便有冇血？月經多唔多？」 | Screen serious causes: malignancy, thyroid, anaemia, CKD |
| 2:30–3:30 | PMHx, DHx, allergy, FHx, social Hx | 「你有冇長期病？食緊咩藥？有冇敏感？屋企人有冇乜嘢病？你做咩工？瞓得好唔好？有冇飲酒/食煙？」 | Drug causes (sedatives, β-blockers); sleep disorders; substances |
| 3:30–4:30 | ICE + hidden agenda (mood screen) | 「你自己覺得攰嘅原因係乜？最擔心嘅係咩？你今日嚟想我幫你做啲咩？」 then 「最近開唔開心？有冇提唔起勁做嘢？瞓得點？」 | ICE = direct marks; depression screen (PHQ-2) is the #1 hidden agenda |
| 4:30–5:15 | Summarise back to patient, check understanding | 「我整理下：你攰咗X個月，仲有…你最擔心…你想…有冇嘢我講漏咗？」 | Demonstrates active listening → interpersonal marks |
| 5:15–6:00 | Explain plan, safety-net, close | 「我建議驗下血先，包括血常規、甲狀腺功能同血糖。如果情況加重，或者你有任何唔舒服，隨時返嚟。」 | Safe closure, safety-net statement, patient-centred |
Uncovering the hidden agenda: "Tiredness" is the ticket of admission. The real reason may be: fear of cancer, worry about heart disease, marital/work stress causing depression, or insomnia. The key question is: 「其實你今日點解決定嚟睇醫生？有冇嘢特別擔心？」 ("What made you decide to come today? Is there something you're particularly worried about?")
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did tiredness start? Acute vs gradual? | 「幾時開始覺得攰？係突然定慢慢嚟？」 | Acute → infection/acute illness; Chronic → depression, anaemia, thyroid | Acute: viral illness; Chronic: depression, hypothyroidism |
| Severity/Function | Does it affect your work/daily life? | 「攰到有冇影響返工或者日常生活？」 | Functional impact is a CRF marks item | Significant impact → organic or severe psych |
| Sleepiness vs fatigue | Do you feel sleepy or just tired/no energy? | 「你係想瞓覺，定係無力無精神？」 | Sleepiness ≠ fatigue [1][2] — different DDx pathways | Sleepiness → OSA, narcolepsy; fatigue → anaemia, depression |
| Sleep quality | How's your sleep? Snoring? Wake up refreshed? | 「你瞓得好唔好？有冇鼻鼾？朝早起身有冇精神？」 | OSA is common and missed; insomnia → depression/anxiety | Snoring + unrefreshing → OSA; insomnia → depression |
| Weight change | Any weight loss or gain? | 「體重有冇變？輕咗定重咗？」 | Weight loss → malignancy, thyroid, DM, TB, adrenal insufficiency; gain → hypothyroidism | Loss: cancer, hyperthyroid, DM; Gain: hypothyroid |
| Fever/night sweats | Any fever or night sweats? | 「有冇發燒？夜晚出汗？」 | Red flag for malignancy, TB, infection | Lymphoma, TB, endocarditis |
| Appetite | How is your appetite? | 「胃口點？」 | ↓appetite → depression, malignancy, CKD | Depression if ↓appetite + low mood |
| Cold intolerance | Do you feel cold more than before? | 「最近有冇特別怕凍？」 | Classic hypothyroidism clue | Hypothyroidism |
| Bowel habit | Any constipation or diarrhoea? | 「大便點？有冇便秘或者肚瀉？」 | Hypothyroid → constipation; coeliac/IBD → diarrhoea + fatigue | Hypothyroid, coeliac, CRC |
| Menstrual Hx ♀ | Are your periods heavy or irregular? | 「月經多唔多？有冇唔準？」 | Menorrhagia = commonest cause of IDA in young women | Iron deficiency anaemia |
| Thirst/polyuria | Feeling thirsty? Going to toilet more often? | 「有冇特別口渴？小便多咗？」 | DM, hypercalcaemia, CKD | DM, CKD |
| Mood – PHQ-2 | In last 2 weeks: low mood? Lost interest in things? | 「最近兩個禮拜有冇覺得唔開心？有冇對以前鍾意嘅嘢冇晒興趣？」 | Depression is the #1 masquerade of fatigue [1][3] | Depression / adjustment disorder |
| Stress/life events | Any major stress at work or home? | 「最近工作或者屋企有冇壓力大嘅事？」 | Hidden agenda: work burnout, relationship issues | Psychosocial causes |
| Drug history | What medications/supplements are you taking? | 「你食緊咩藥？有冇食健康產品？」 | β-blockers, antihistamines, sedatives, statins can cause fatigue | Drug-induced fatigue |
| PMHx | Any chronic diseases? DM/HT/heart/kidney/liver? | 「你有冇長期病？糖尿、高血壓、心臟病、腎病？」 | CKD, HF, DM, hepatitis B cause fatigue | CKD (normocytic anaemia), HF, chronic hepatitis |
| Alcohol/smoking | Do you drink alcohol? How much? | 「有冇飲酒？飲幾多？」 | Alcohol → liver disease, depression, sleep disruption | Liver disease, depression |
| FHx | Any family history of thyroid, DM, or cancer? | 「屋企人有冇甲狀腺病、糖尿或者癌症？」 | Genetic predisposition | Thyroid disease, DM, haematological malignancy |
| Occupation | What is your job? Night shifts? | 「你做咩工？有冇返夜班？」 | Shift work → circadian disruption; occupational stress | Sleep disorder, burnout |
Case Report Form Answer Builder
- CC: "Tiredness for [X weeks/months]"
- HPI must include: duration; onset (gradual vs sudden); severity (functional impact on work/ADLs); associated symptoms (weight change, fever, night sweats, mood change, sleep quality, appetite); aggravating/relieving factors; relevant negatives (no chest pain, no SOB, no GI bleeding)
- Examples: "Patient is worried that tiredness may indicate a serious underlying illness (e.g. cancer)" / "Tiredness is affecting work performance" / "Spouse noticed patient is not his/her usual self and urged visit"
- How to phrase: One sentence linking the symptom to the patient's motivation for attending today
| Example Wording | |
|---|---|
| Ideas | "Patient thinks the tiredness may be due to low blood / anaemia" or "Patient thinks it might be related to stress at work" |
| Concerns | "Patient is worried it could be something serious like cancer" or "Worried about losing her job due to poor performance" |
| Expectations | "Patient wants a blood test to check" or "Wants reassurance that nothing is seriously wrong" or "Wants a sick leave certificate" |
- In a 45-year-old male with no red flags and no obvious organic symptoms → Depression or Adjustment disorder with depressed mood [3]
- In a young menstruating female → Iron deficiency anaemia
- Minimum supporting evidence: PHQ-2 positive (low mood + anhedonia ≥ 2 weeks) + sleep disturbance + ↓appetite + no organic red flags → depression. OR: heavy periods + pallor + fatigue → IDA
- Choose based on the stem clues given in the station
| DDx | Key Discriminator |
|---|---|
| Hypothyroidism | Cold intolerance, constipation, weight gain, dry skin, bradycardia; confirm with TSH |
| Iron deficiency anaemia | Menorrhagia or GI blood loss, pallor, microcytic hypochromic indices |
| Obstructive sleep apnoea | Snoring, witnessed apnoeas, obesity, daytime sleepiness (not just fatigue), large neck |
(Adjust based on patient demographics and stem clues)
| Domain | Problem |
|---|---|
| Biological | Underlying cause of fatigue (e.g. anaemia / hypothyroidism / undiagnosed DM) requiring investigation |
| Psychological | Depressed mood / anxiety / health anxiety related to chronic fatigue |
| Social/Functional | Impaired work performance / strained family relationships / reduced quality of life due to fatigue |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Depression (most likely dx) | No reliable physical sign in brief FM station | Use PHQ-2/PHQ-9 screening questions; observe psychomotor retardation, poor eye contact, flat affect | Depression is a clinical diagnosis; exam clues include affect, appearance |
| Iron deficiency anaemia | Conjunctival pallor | Pull down lower eyelid, inspect palpebral conjunctiva for pallor | Pallor indicates Hb < ~9-10 g/dL; specific sign of anaemia [6][7] |
| Hypothyroidism | Bradycardia + delayed ankle jerk relaxation | Check resting pulse rate; elicit ankle reflex and observe slow relaxation phase | Bradycardia with slow-relaxing reflexes is classic for hypothyroidism [8] |
| OSA | Large neck circumference ( > 43cm M / > 41cm F) + Mallampati class III-IV | Measure neck with tape; inspect oropharynx | Predicts upper airway narrowing → OSA [2] |
| Heart failure | Elevated JVP + bilateral ankle oedema | 45° recumbent, inspect internal jugular; press pretibial area for pitting | Volume overload signs confirm HF |
| Adrenal insufficiency | Hyperpigmentation (palmar creases, buccal mucosa) | Inspect palms, inside mouth | ↑ACTH → ↑MSH → pigmentation; pathognomonic for primary adrenal insufficiency [5] |
| Malignancy | Lymphadenopathy (cervical, supraclavicular, axillary) | Palpate all lymph node stations | Non-tender, firm, fixed nodes suggest malignancy |
Top Traps That Lose Marks
- Not screening for depression — the #1 cause of chronic fatigue in primary care, and the most commonly tested hidden agenda. Always ask PHQ-2.
- Confusing sleepiness with fatigue — sleepiness (propensity to fall asleep) points to sleep disorders (OSA, narcolepsy); fatigue (lack of energy despite no sleep drive) points to depression, anaemia, endocrine. This distinction is explicitly tested [1][2].
- Forgetting to ask about medications — β-blockers, antihistamines, sedatives, antidepressants, statins are common culprits.
- Not asking menstrual history in women — iron deficiency anaemia from menorrhagia is the commonest organic cause in premenopausal females.
- Not exploring ICE — easy marks lost. "What do you think is causing this? What worries you? What were you hoping we'd do today?"
- Jumping to investigations without exploring psychosocial — the examiner wants to see you ask about stress, mood, function, not just order bloods.
- Forgetting the hidden agenda — "Why today?" Always ask what prompted the visit now.
Must-Not-Miss Red Flags → Urgent Referral
- Unintentional weight loss > 5% in 6 months → malignancy workup
- Night sweats + lymphadenopathy → haematological malignancy
- Severe anaemia (Hb < 7) → urgent haematology referral / transfusion
- Suicidal ideation → immediate psychiatric assessment
- New heart failure symptoms (orthopnoea, PND, oedema) → urgent cardiology
- Postural hypotension + hyperpigmentation + hypoNa → adrenal crisis risk → urgent endocrine
Shortest safe management/safety-net line: 「我今日會安排你驗血，包括血常規、甲狀腺、血糖、肝腎功能。大約一個禮拜覆診睇結果。如果期間你覺得更加辛苦、有發燒、消瘦、或者情緒好差，記住即刻返嚟或者去急症。」
High Yield Summary
What to ASK: PHQ-2 (mood + anhedonia), sleep quality/snoring, menstrual Hx (♀), weight change, medications, red flags (fever/night sweats/weight loss/bleeding), ICE, "why today?"
What to WRITE on CRF: CC = "Tiredness × [duration]"; RFC = the patient's real motivation (fear/function/expectation); ICE verbatim; Most likely Dx = depression (if no organic clues) or IDA (if menorrhagia/pallor); DDx = hypothyroidism, IDA/anaemia, OSA; BPS = biological (cause needs Ix), psychological (low mood/anxiety), social (work/family impact); Physical sign = conjunctival pallor (if anaemia) or psychomotor retardation (if depression)
What NOT TO MISS: Depression screening, medication causes, menstrual history in women, sleepiness vs fatigue distinction, hidden agenda exploration
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: CFB (FM02) Introduction to common problems - Differentiating the normal from the abnormal.pdf (p.10) [2] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.297–299) [3] Past papers: 2018 Fourth Summative SAQ.pdf (Q10, p.5) [4] Senior notes: Block A - Chronic Kidney Disease and its Complications.pdf (p.6) [5] Senior notes: Ryan Ho Endocrine.pdf (p.71); Ryan Ho Fundamentals.pdf (p.440) [6] Senior notes: Ryan Ho Haemtology.pdf (p.10); Ryan Ho Fundamentals.pdf (p.380) [7] Senior notes: Block A - Pallor_ diagnosis of anaemia; nutritional anaemia; anaemia of systemic diseases.pdf (p.3) [8] Senior notes: Maksim Medicine Notes.pdf (p.90)
Tinnitus
Tinnitus is the perception of sound, such as ringing, buzzing, or hissing, in the ears or head without an external acoustic stimulus.
Toe Pain
Toe pain is discomfort in one or more toes that may arise from trauma, gout, bunions, hammertoe deformities, ingrown toenails, infections, or peripheral neuropathy.