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)
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