Be alert for red flags in fatigue

Fatigue in the majority of patients will be due to lifestyle factors, psychosocial problems, sleeping difficulties or may remain unexplained.1 In most cases, uncomplicated tiredness will resolve on its own.2 Almost three-quarters of consultations for fatigue are isolated incidents, and the patient does not return for follow-up.3

Watchful waiting

If no physical cause is suspected following a thorough clinical history and physical examination, it may be appropriate to delay testing.2 Provide patients with advice to address any identified non-somatic problems and re-examine the patient after a period of watchful waiting.2, 4, 5

Symptoms that may warrant immediate investigation

The following symptoms ('red flags') may indicate more serious underlying pathology and require further investigation:1,2

  • fever
  • unintentional/unexplained weight loss
  • unexplained lymphadenopathy (eg, lymph node that is non-tender, firm, hard, > 2 cm diameter, progressively enlarging, supraclavicular, or axillary)
  • other features of malignancy (eg, haemoptysis, dysphagia, rectal bleeding, breast lump, post-menopausal bleeding)
  • dyspnoea
  • recent onset or progression of cardio-respiratory, gastroenterological, neurological or rheumatological symptoms. 

Read more about targeted testing.

Recent onset fatigue in a previously well, older patient may indicate underlying disease.
Australian Therapeutic Guidelines. Fatigue: diagnostic approach to primary care, 2011.

Find out more about

  1. Therapeutic Guidelines Limited. Fatigue: diagnostic approach to fatigue in primary care. Melbourne, 2011. [Online] (accessed 3 April 2014).
  2. Hamilton W, Watson J and Round A. Investigating fatigue in primary care. BMJ 2010;341. [Online]
  3. Kenter EG, Okkes IM, Oskam SK, et al. Tiredness in Dutch family practice. Data on patients complaining of and/or diagnosed with "tiredness". Family Practice 2003;20:434-40. [PubMed]
  4. Koch H, van Bokhoven MA, ter Riet G, et al. Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial. Br J Gen Pract 2009;59:e93-100. [PubMed]
  5. van Bokhoven MA, Koch H, van der Weijden T, et al. The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial. Implement Sci 2012;7:29. [PubMed]