Intended for healthcare professionals

Practice Rational Testing

Investigating fatigue in primary care

BMJ 2010; 341 doi: (Published 24 August 2010) Cite this as: BMJ 2010;341:c4259
  1. William Hamilton, general practitioner 1, professor of primary care diagnostics2,
  2. Jessica Watson, academic clinical fellow, ST2 GP trainee3,
  3. Alison Round, general practitioner4
  1. 1Mount Pleasant Health Centre, Exeter EX4 7BW
  2. 2Peninsula College of Medicine and Dentistry, Exeter EX2 4SG
  3. 3Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, Bristol BS8 2AA
  4. 4Castle Place Practice, Tiverton EX16 6NP
  1. Correspondence to: W Hamilton w.t.hamilton{at}

    Tiredness is a common presentation in general practice, but how useful are investigations, and what tests should be done and how soon?

    Learning points

    • Tiredness is a common complaint, reported in 5-7% of general practice encounters

    • Investigations may exclude diagnosis and reassure the patient, but they have a low rate of identifying any underlying disease

    • Investigations are warranted in those who have not recovered after one month or whose initial presentation is atypical or is associated with “red flag” symptoms

    • Be alert for important but easily missed conditions such as carbon monoxide poisoning, coeliac disease, pregnancy, and sleep apnoea

    • Further evidence is needed to establish best practice in the investigation of the tired patient

    A 48 year old teacher with a two month history of continuing tiredness visits her general practitioner. She has an unremarkable medical history and no history of recent infection, and she denies unusual stress. She has not lost any weight. Clinical examination is normal with a blood pressure of 130/75 mm Hg, a regular pulse at 70 beats per minute, and no lymphadenopathy.

    The problem

    Fatigue is a normal part of life, but it can also be a symptom of disease, including serious illnesses. It is a common complaint in primary care, exceeded only by complaints of cough.1 Five to seven per cent of patients attending primary care have a primary complaint of fatigue, with this proportion being remarkably consistent across Western countries2 3 4 5 and over time.4 The proportion of patients presenting with fatigue as an additional complaint is nearly three times as high.3 6 Almost three quarters of consultations for fatigue are isolated episodes, with no follow-up …

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