MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Fatigue needs structured assessment. Establishing what the person can no longer do helps distinguish fatigue, sleepiness, breathlessness and muscle weakness.
Define the complaint and its pattern
Clarify onset, course, sleep, recovery, triggering activity and effects on work or daily life. Ask about fever, weight loss, bleeding, pain and cardiopulmonary, neurological or endocrine symptoms. Review prescribed medicines, self-medication and substances; explore mood, anxiety and social difficulties without prematurely assuming a psychological cause. Objective weakness or exertional breathlessness requires its own assessment even when described as tiredness.
[1][2]Choose proportionate investigations
Examination and duration guide testing for plausible causes such as anaemia, glucose disturbance, kidney or liver disease and thyroid dysfunction. Consider B12 deficiency with paraesthesia, imbalance, dietary restriction or malabsorption, even without anaemia. Extensive serology or multiple vitamin assays cannot replace a documented hypothesis. Acute illness may distort thyroid tests.
[1][3][2]Distinguish perceived fatigue, sleepiness, exertional intolerance and objective muscle weakness. Explore sleep, schedules, pain, infection, medicines and mental health without prematurely assigning a functional cause. Suspected thyroid disease should have a clinical basis, as acute illness may distort tests. Interpret targeted investigations in light of pre-test probability.
[1][2]Recognise patterns needing further assessment
Rapid deterioration, organ-specific findings, weight loss or suicidal risk changes referral priority. Prolonged fatigue with post-exertional malaise, unrefreshing sleep and cognitive difficulties may suggest ME/CFS after assessment for other causes; duration alone is insufficient. In that pattern, avoid a compulsory programme of fixed activity increases that disregards exacerbations.
[1]Review symptoms and functioning
Agree concrete measures such as sleep quality, activity tolerance and essential daily tasks. Explain findings and limitations of the first assessment, then tailor review to the course. Follow-up should detect new signs and assess the effects of decisions. Do not repeat normal test panels indefinitely without re-examining the complaint and reconsidering the hypotheses.
[1][3]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A 36-year-old teacher reports substantial fatigue for several months after infection. Previously ordinary activity causes delayed, prolonged worsening and sleep is unrefreshing. Initial examination shows no acute organ failure.
Should exercise be increased every week according to a fixed schedule?
Read the reasoning
Not on this basis alone. Characterise post-exertional malaise and assess alternative diagnoses. ME/CFS may be considered within an appropriate clinical assessment. Activity advice should account for individual limits and exacerbations, with planned review rather than enforced progression.
References and scope
- Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management (NG206) ↗
- Thyroid disease: assessment and management (NG145) ↗
- Vitamin B12 deficiency in over 16s: diagnosis and management (NG239) ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.