Matilda Williams

Age: 26 years old female

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s name:  Matilda Williams

Age: 26-year-old female

Past medical history

  • Asthma

Drug and Allergy History

  • Salbutamol PRN
  • Clenil Modulite 200mcg, 2 puffs twice daily
  • No Known drug allergy 

Recent notes/consultation

  • Nil

Patient booked routine video appointment to discuss concerns

Patient's Story (Role player’s brief)

Patient’s Story 

You are Matilda Williams, a 26-year-old female.  You’ve been feeling constantly tired for the past 8 weeks, and it doesn’t seem to be improving. This started suddenly about 10 weeks ago, shortly after a flu-like illness. The fatigue worsens even with minor physical activity, whether at home or at work.

Only say the following if specifically asked:

You often wake up feeling unrefreshed, flu-like and stiff, despite sleeping for long hours.

Your mood is fine. You have no symptoms of low mood or mental health concerns.

Social History: You are a non-smoker, do not drink alcohol, and live with your husband and two children. You work as an accountant 

Ideas: You’re unsure of the cause but wonder if it could be a vitamin deficiency.

Concerns: You’re struggling to manage at work due to persistent fatigue.

Expectations: You’d like help understanding what’s causing this and guidance on what to do next.

Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor. 

Marking Scheme

Data Gathering and Diagnosis 

  • Ask about the onset, duration, and progression of the tiredness — when it started, and whether it’s getting better, worse, or staying the same.
  • Ask whether the tiredness is worsened by light activity, and whether any flu-like illness preceded it (to explore possible post-viral fatigue).
  • Ask whether she wakes feeling refreshed and if she sleeps more than usual.
  • Ask about difficulty concentrating, or “brain fog”.
  • Ask about generalised body aches or joint stiffness, particularly in the morning.
  • Explore mood, asking about low mood, lack of motivation, and screen for suicidal thoughts or self-harm (important to exclude depression presenting as fatigue).
  • Ask about cold intolerance, skin changes, constipation (to screen for hypothyroidism).
  • Ask about urinary frequency, thirst, and weight changes (to rule out diabetes).
  • Ask whether her periods are regular.
  • Ask about smoking, alcohol, and drug use.
  • Ask about her work and home situation, and whether she feels able to cope with day-to-day responsibilities.
  • Ask if she drives, and whether her tiredness has affected her ability to drive safely (important for DVLA fitness-to-drive implications).  
  • Give a diagnosis of chronic fatigue syndrome

Example of explanation to patient​

Matilda, thank you for sharing everything with me. I can hear how much this ongoing tiredness is affecting your daily life, especially with work and looking after your family.

You mentioned that you were wondering if a vitamin deficiency might be causing your symptoms, that’s a really valid concern, and it’s something we’ll definitely check for in your blood tests.

However, based on what you’ve told me, particularly the fatigue following a flu-like illness, feeling worse after minimal activity, and waking up feeling unrefreshed, it’s possible you’re experiencing something called chronic fatigue syndrome.

This is a long-term condition that often follows a viral illness that causes extreme fatigue that doesn’t improve with rest and can flare from time to time. 

Like I mentioned earlier about your concerns of vitamin deficiency, we’ll still do a full set of blood tests to check for things like vitamin B12, vitamin D levels, folate,  iron levels, thyroid function, sugar levels to rule out diabetes and other markers, just to make sure we’re not missing anything treatable.

If all of your blood tests come back normal, I would recommend a referral to a specialist chronic fatigue service. These services typically involve a team that includes clinical psychologists and specialist physiotherapists, who offer a range of treatment options. This includes energy management strategies, pacing, and talking therapies/ cognitive behavioural therapy (CBT). These approaches can help you understand your energy limits, plan your day to avoid overexertion, prioritise tasks, and gradually increase your activity levels in a way that’s safe, realistic, and sustainable.

In the meantime, it would be helpful for you to keep a symptom diary. This can help you understand patterns in your fatigue, recognise what activities trigger flares, and get a clearer sense of your overall energy levels.

I’d also like to introduce you to an approach called an energy management plan. This covers all forms of activity, not just physical tasks, but also mental, emotional, and social activities. The goal is to help you use the energy you do have effectively, while avoiding what’s called post-exertional malaise, a worsening of symptoms after doing too much.

We encourage a technique called pacing. This means planning periods of rest and activity, making a list of essential tasks, breaking them into smaller chunks, prioritising what’s most important, and spreading activities out over time. It’s about moving at a pace your body can manage, and avoiding energy crashes by staying within your limits.

There’s also the option of talking therapy, which we can refer you to. It’s not just for low mood, it’s designed to help people adjust to living with long-term conditions, by exploring different ways of thinking and coping with ongoing symptoms.

If work has become difficult, I can provide a fit note for amended duties or some time off, depending on what works best for you.

Sometimes chronic fatigue can start to affect a person’s mood or emotional wellbeing, even if it hasn’t yet. If you notice that happening, it’s really important to seek help early, and we’ll support you.

I’ll also share some leaflets and point you towards support groups, which many people find helpful for learning more and connecting with others going through similar experiences.

Management

Management

  • Arrange a comprehensive set of blood tests to investigate underlying causes of fatigue. These should include: FBC, U&Es, ESR, CRP, TFTs, HbA1c, Vitamin D, B12, Ferritin, Folate, Coeliac Screen, and Creatine Kinase (to rule out neuromuscular causes).
     If the patient were over 60, consider adding a myeloma screen.
  • Inform the patient that if all blood tests return normal, you would consider referral to a specialist chronic fatigue service, which offers energy management programmes and access to specialist physiotherapists to support with symptom management.
  • Offer a fit note for time off work or suggest amended duties, depending on how her fatigue is affecting her daily functioning and personal preference.
  • Recommend talking therapy, such as counselling or CBT, which may help improve coping strategies and overall functioning, even if mood is currently stable.
  • Introduce the concept of pacing — a self-management technique that involves recognising one’s energy limits, breaking down tasks into manageable chunks, prioritising essential activities, and balancing rest and activity to avoid overexertion.
  • Advise that while her mood appears okay now, fatigue can sometimes affect mental health, and she should seek help promptly if she notices changes in mood, motivation, or emotional wellbeing.
  • Offer written information and leaflets about fatigue and chronic fatigue syndrome, and direct her to relevant support groups for peer support and further guidance.

Learning point from this station: ​

This station highlights the recognition, assessment, and management of Chronic Fatigue Syndrome (CFS), a complex and often misunderstood condition that requires sensitive handling and structured support in primary care.

According to the National Institute for Health and Care Excellence (NICE), a diagnosis of CFS should be suspected in adults if fatigue has persisted for six weeks or more, has significantly impacted daily functioning, cannot be explained by another condition, and is accompanied by all of the following features:

  • Debilitating fatigue that worsens with activity, is not caused by excessive physical, emotional, cognitive or social exertion, and is not relieved by rest
  • Post-exertional malaise (PEM)- a situation where even small amounts of physical, mental, or emotional effort can lead to a significant worsening of symptoms. The symptoms are out of proportion to the level of activity and the recovery takes a long time
  • Poor sleep or waking feeling unrefreshed, often feeling flu-like or stiff when they wake up
  • Cognitive difficulties (e.g. brain fog, memory issues, word-finding difficulty, poor concentration)

There is no specific diagnostic test for CFS. Thorough investigations must be conducted to exclude other causes before diagnosis, including but not limited to : FBC, U&Es, LFTs, ESR, CRP, thyroid function, HbA1c, ferritin, B12, folate, vitamin D, creatine kinase, and coeliac screen (IgA tissue transglutaminase).

If diagnostic criteria are met and symptoms have persisted for 3 months, referral to a specialist CFS service should be arranged as per NICE guidelines. However, clinical judgement should prevail, referral may be appropriate before 3 months if symptoms are severe or debilitating and all investigations are normal.

If a patient does not yet meet the criteria for referral to a specialist CFS service in your local pathway, several supportive strategies can still be initiated in primary care:

  • Energy Management: This is most effective when delivered with input from a specialist team, but there are key steps that can be introduced in primary care. It starts with the patient gaining insight into their overall level of activity and how it relates to their symptoms. Patients should be encouraged to keep a symptom and activity diary — this helps identify triggers that worsen fatigue and recognises patterns of post-exertional malaise. This involves creating a personalised plan that takes into account physical, mental, emotional, and social activities. It helps the patient stay within their energy limits, avoid post-exertional malaise (PEM), and develop a more balanced, sustainable routine.
  • They can also introduce pacing — which involves planning daily activities in a way that avoids overexertion — breaking tasks into smaller chunks, taking regular rest breaks, and spreading out activities over time. 
  • Cognitive Behavioural Therapy (CBT): CBT can be useful for individuals struggling with the emotional impact of long-term illness. It aims to support coping mechanisms, improve daily functioning, and reduce stress related to chronic fatigue.
  • Physiotherapy or Occupational Therapy: Specialist input may be helpful for patients with reduced mobility or those who are ready to safely increase their activity level. These professionals can offer graded activity plans, support with daily function, and pacing strategies.
  • Pain Management: If pain is a significant symptom, ensure appropriate assessment and consider initiating treatment or referring to specialist pain services where necessary.
  • Sleep and Mood: Encourage sleep hygiene strategies to improve rest and reduce fatigue. If there are signs of low mood or coexisting depression, these should be appropriately assessed and managed, as they can significantly impact recovery.

Do not advise unstructured exercise (e.g. gym sessions or “pushing through” fatigue), as this may worsen symptoms significantly.

Further reading