Table 11Guideline recommendations(52)

InvestigationAlways perform?Perform only in these situations
Appropriate assessment for presence of anxiety or depressionYes
Appropriate assessment of current life stresses and past trauma and abuseYes
Focused history and physical examination with special emphasis on medications, existing chronic illnesses, and presence of infection, particularly viralYes (to determine whether lab investigations are necessary)
Haemoglobin testNoPresence of pallor, tachycardia, dyspnoea, or other symptom suggesting anaemia
Dietary of family history suggesting risk of anaemia
Patient older than 65*
White blood cell countNoFever or other evidence of infection
Weight loss, lymphadenopathy
Patient older than 65*
ESR**NoEvidence of inflammatory arthritis
Concern about occult malignancy
Patient older than 65*
Electrolyte assessmentNoPatient taking medication known to affect electrolyte balance (eg. Diuretics, steroids)
Indication of a medical condition causing electrolyte imbalance (Cushing’s disease, Addison’s disease, parathyroidism)
Renal function tests**NoPatient taking medication known to affect renal function
Symptoms or signs possibly associated with renal disease (elevated blood pressure, oedema, generalised pruritis)
Glucose test (urinalysis only for investigating polydypsia and polyurea)NoHistory of gestational diabetes
Known diagnosis of diabetes mellitus
Symptoms of polydypsia and polyurea
Unexplained peripheral neuropathy
Patient older than 65*
TSHNoPresence of goitre
History of thyroiditis
Symptoms and signs suggesting hypothyroidism (dry hair and skin, change in bowel habit, change in menses)
Patient older than 65*
Chest X-ray**NoSmoker with cough or haemoptysis (especially if older than 50)
History of exposure to asbestos or other pulmonary occupational hazard
Exposure to tuberculosis
Other investigations**NoAs indicated by history and physical examination findings
Weight loss and changes in bowel habit should prompt gastrointestinal investigation*

The elderly were not well represented in the literature. The group’s consensus, after consultation with experts in care of the elderly, is that they are more likely to have physical causes of fatigue, especially if the symptom is new. The guideline group recommended lowering the threshold for investigation in this group.


Recommended by group consensus only; no evidence available in literature.

From: 8, The Diagnostic Process

Cover of Referral Guidelines for Suspected Cancer in Adults and Children
Referral Guidelines for Suspected Cancer in Adults and Children [Internet].
NICE Clinical Guidelines, No. 27.
Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences, University of Leicester.
Copyright © 2005, National Collaborating Centre for Primary Care.

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