22 General lethargy and tiredness

22 General lethargy and tiredness
Appropriate introduction
Confirms patient’s name and age
Explains reason for consultation
Obtains consent
Open question to elicit presenting complaint
Allows patient to open up, listens carefully, remains silent and
does not interrupt the patient
Signposts: e.g. ‘Mr Gregory, thank you for telling me about this
problem. I would like to ask a few more detailed questions. Is
that all right?’
History of presenting complaint:
Onset (how it started)
Character (what the patient means by tiredness)
Time (duration)
Alleviating factors
Exacerbating factors
Severity (in comparison with other episodes of tiredness)
Asks if there is a pattern with activities/daily routine
Asks about menstrual disturbances (if patient female)
Establishes sleep pattern
Asks if patient is suffering from any other symptoms
Asks about any recent illnesses
Previous episodes of lethargy/tiredness
Depression screening: asks about mood, previous history of
depression and sleeping patterns
Asks closed focused questions to rule out specific common
causes of lethargy:
• Thyroid dysfunction (sweating, tremor, dry hair, neck discomfort, eye symptoms, bowel changes, menstrual irregularities)
• Anaemia (shortness of breath, chest pain, palpitations, menorrhagia)
• Diabetes mellitus (polydipsia, polyuria, recurrent infection)
• Cancer (weight loss, night sweats, family history of cancers,
cough, diarrhoea, melaena)
• Hypopituitarism (loss of appetite, nipple discharge, loss of
• Chronic kidney disease/nephrotic syndrome (ankle swelling,
• Chronic infection (fevers)
• Chronic fatigue syndrome symptoms (sore throat, headaches,
muscle pains, exacerbated by exertion)
• Obstructive sleep apnoea (unrefreshing sleep, feeling sleepy
in the day, loud snoring, waking up suddenly in the night, loss
of libido, irritability)
• Depression (mood, anhedonia, sleep, appetite, concentration)
Review of systems
‘Red flags’:
• Night sweats
• Fevers
• Weight loss
• Loss of appetite
• Palpable lymph nodes
Past medical history
Family history:
• Cancers
• Endocrine disorders, especially thyroid disorders and diabetes
• Depression
Drug history:
• Over-the-counter medication
Social history:
• Smoking
• Alcohol
• Illicit drug use
• Stressors in social life (relationship, financial, etc.)
• Change in work/occupation
• Symptoms of depression or anxiety
• Recent foreign travel
Use of non-verbal cues, e.g. good eye contact, nodding head
and good body posture
Systematic approach
Explores and responds to ICE:
• Ideas
• Concerns
• Expectations
Shows empathy
Non-verbal skills
Avoids technical jargon
Devises holistic management plan and addresses psychosocial
issues as well as medical problems
Offers to answer any questions
Thanks patient
OSCEs for Medical Finals, First Edition. Hamed Khan, Iqbal Khan, Akhil Gupta, Nazmul Hussain, and Sathiji Nageshwaran.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.