HNY Policy and Pathway Repository - Humber

Referral of ongoing fatigue that is medically unexplained and has not resolved with usual primary care interventions.

Referral is to diagnose Chronic Fatigue Syndrome and offer treatment options if indicated. 

Signs and symptoms that can be caused by other serious conditions should not be attributed to Chronic Fatigue Syndrome  without consideration of alternative diagnosis or co-morbidities.  In particular, the following features should be investigated:

•  Localising focal neurological signs.
•  Signs and symptoms of inflammatory arthritis or connective tissue disease.
•  Signs and symptoms of cardio respiratory disease.
•  Significant weight loss.
•  Clinically significant lymphadenopathy. 

Exclude Red Flag Symptoms

Please exclude established medical disorders known to cause Chronic Fatigue and would indicate differential diagnosis e.g.

• Adrenal Insufficiency
• Chronic Infection
• Immuno-defficiency
• Major neurological Disease
• Rheumatic diseases
• Functional Neurological disorder
• Alcohol / substance misuse
• Eating disorders – anorexia and obesity
• Anaemia
• Coeliac disease
• Malignancy
• Pregnancy and the menopause
• Primary sleep disorder / sleep apnoea
• Thyroid disease
• Organ failure eg emphysema, cirrhosis
• Reversible causes of fatigue e. g. medication, recent surgery
• Moderate to severe depressive illness- please refer to mental health services.
• Psychotic illness.
• Please also exclude generalised anxiety disorder -, where a referral to High Intensity IAPT would be more appropriate.

Referral to health trainers for basic lifestyle management including fatigue advice / weight loss / exercise advice/ benefit advice.

Referral to IAPT if fatigue may be as a result of Anxiety or Depression

Patients must meet the FUKUDA criteria outlined below -

• Over 18 years old
• Persistent and debilitating fatigue
• Onset of 6 months duration
• Susbtantial reduction in occupational, education, social and personal activities

Must also experience more than 3 of these symptoms -

• Self-reported problems with short term memory and concentration
• Frequent sore throat
• Tender cervical and axillary glands
• Muscle pain, joint pain without swelling or redness
• Headaches of new type, pattern or severity - not explained by migraine or previously experienced headache disorder
• Unrefreshing sleep
• Post-exertional malaise lasting more than 24 hours
• The current BMI must be included on the referral form and the following blood tests must have been undertaken and the results enclosed  with the referral;
• Full blood count, Serum Ferratin, Us and Es, LFTs and bone profile, Coeliac antibody, C reactive protein,HBA1C, Thyroid function test, B12, autoimmune serology, serum cortisol, anti CCP and folate.

The referral form must be fully completed, including a clinical summary and past mental health/social situation in order for us to be able to make clinically reasoned triage. 

Currently referrals can be made by e mail/ post and are soon to be ERS.  The referral will be triaged and the GP made aware of the outcome of the Triage.  Patients are then placed upon a waiting list for an assessment for Chronic Fatigue Syndrome.   Please not that we are unable to monitor the patients’ mental health whilst they are on the waiting list.  Once the patient has been assessed, if a diagnosis of Chronic Fatigue Syndrome is applicable then they can be offered further treatment with the service.  The GP will be made aware of the outcome of the assessment.  This will be via a written letter to the GP communicated via either e mail or ERS.

Complete referral form on AREDENS

Patient information leaflet

Please ensure that the referral form is fully completed including clinical summary and the blood results are enclosed with this.  We are unable to accept referrals when the blood results are not enclosed.  Please also include any information regarding the patients’ journey through mental health and / or acute services so that we are able to triage the likelihood of these being the cause of the fatigue.