Case 27: Fatigue

Opening scenario

Lakeesha Willis, a 28-year-old female; , comes to the doctor’s office because of fatigue.

Vital signs

• Temperature: 97.5°F (36.4°C)
• Blood pressure: 110/65 mm Hg
• Heart rate: 60/min
• Respirations: 15/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Speak slowly and without very much emotion.
• Keep your face expressionless, as it would be during sleep.
• If the examinee tests the strength of your arms or legs by asking you to press against them, press back only weakly.
• You are not aware of the meanings of medical terms (e.g., MRI, CT) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Do you think I am a bad mother?”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I have been really tired lately.
• Onset
• Maybe for 5 months now.
• Constant/intermittent
• All the time.
• Precipitating events
• Well, I gave birth to my twins 6 months ago.
• Progression
• It has been getting worse.
• Previous episodes
• No.
• Alleviating factors
• Nothing. Not even sleeping helps.
• Aggravating factors
• When the boys cry a lot and wake each other up all the time. Sometimes I just do not get any sleep for nights in a row.
• Associated symptoms
• I have been feeling really cold lately. I need to put on a sweater when nobody else does.

Review of systems specific to fatigue with postpartum onset

• Trauma
• No.
• Headache
• No.
• Nausea/vomiting
• No.
• Fever/chills
• No.
• Racing of the heart
• No.
• Rash/skin changes
• No.
• Shortness of breath
• No.
• Urinary problems
• No.
• Bowel problems
• No.
• Sleep problems
• I do not sleep much. I am up with one or the other of the twins at night a lot.
• Appetite
• I do not have much of an appetite.
• Weight changes
• I have not been able to lose my baby weight yet.
• Recent infections
• No.
• Dizziness
• Sometimes I feel dizzy when I stand for a long time. Not often, though.
• Dry hair
• Maybe, I do not really get to use any hair products. I do not have time for things like that, with the twins and all.
• Lactation
• I have not been able to breastfeed. I feed the twins formula.
• Mood
• I have not really been happy the past few months. I am just so exhausted.
  • Loss of interest
  • I am too tired to do any of the fun things I used to do.
  • Guilt/low self-esteem
  • I know this should be the best time of my life with the children just being born, but I am just not happy.
  • Poor concentration
  • I am trying my best, but I forget to do simple things all the time, like closing the cabinet doors or taking out the trash.
  • Psychomotor agitation or retardation
  • No.
  • Suicidality
  • No.
  • Social support
  • I live with my husband and the kids. He has been really supportive but he is gone all day because he works an hour away from home.
• Intention to harm the children
• No, I would never harm my children!

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• Cats.
• Medications
• None.
• Hospitalizations
• For the twins' birth and when I had my appendix removed as a child.
• Past surgical history
• I had my appendix taken out when I was about 10 years old.
• Family history
• My mom has bipolar disorder.
• Work
• I am on maternity leave to stay home with the kids. I had planned on going back to my job as aerospace engineer already, but I just have not had the energy.
• Alcohol
• No, not since I found out I was pregnant.
• Recreational drugs
• No, never.
• Tobacco
• No.
• Exercise
• No.
• Diet
• I do not have time to cook or much of an appetite, and my husband is gone most of the day, so I just snack on little things like chips and chocolate.

Sexual history, OB/Gyn

• Sexually active
• I have not really had sex with my husband since the birth of our children. I am just too tired.
  • Pain with intercourse
  • I do not know. Not before I had the twins.
  • Libido
  • I do not really feel like having sex.
• Last menstrual period
• I have not had my period since before I was pregnant.
• Menarche
• When I was 12 years old.
• Duration of period
• About 3–4 days, before I got pregnant.
• Period regular
• Before I got pregnant, yes.
• Pregnancies
• Just with the twins.
• Prenatal history
• It was all normal. They were just born a litte early, at 37 weeks, 4 days.
• Birth history
• It was a normal delivery. The twins were still really small because they were early. And then I had to stay a little longer because there was a lot of bleeding after the delivery and they had to give me transfusions.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Inspection of the conjunctivae
• Neck examination
  • Examination of the thyroid gland
• Cardiovascular examination
  • Palpation of the radial pulse
  • Auscultation of the heart
• Extremities
  • Inspection of the lower extremities
• Skin examination
• Neurologic examination
  • Examination of orientation to person, place, and time
  • Focused mental status examination
    • Flat affect
  • Focused examination of passive and active motion
    • Decreased strength of the arms and legs bilaterally when pushing against the examinee
  • Focused examination of deep tendon reflexes

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on lifestyle modifications to improve mood.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Mrs. Willis, I understand that you have been under a great deal of stress and are feeling exhausted. I think the fact that you came in to see me today because you are concerned about doing a good job caring for your children shows me that you are a good mother and that you are trying to make sure your children get the best possible care. I would like to run a few more tests to find out what is causing your symptoms. Once we have done that, we can make sure that you get the best possible treatment. If you like, I can also get you in touch with one of our social workers and you can talk to her about ways to support you and your family. How does that sound?”

Patient note

Differential diagnoses

1. Sheehan syndrome: This patient presents with symptoms of deficiency of several pituitary hormones. She has symptoms of hypothyroidism (fatigue, cold intolerance, reduced appetite, lack of postpartum weight loss), gonadotropin deficiency (loss of libido, no menses since pregnancy despite bottle-feeding), prolactin deficiency (lactation failure), and ACTH deficiency (weakness, low blood pressure). Together with her history of postpartum hemorrhage requiring transfusions, such a constellation of findings makes it very likely that she is suffering from hypopituitarism due to Sheehan syndrome.
2. Postpartum depression: This patient has several symptoms that should raise concern for postpartum depression, including fatigue, depressed mood, loss of interest, feelings of guilt, low energy, poor concentration, poor appetite, and loss of libido. Her family history of psychiatric illness predisposes her to postpartum depression as well. However, her secondary amenorrhea, lactation failure, cold intolerance, muscle weakness, and low blood pressure are physiological findings that are more consistent with a hormone imbalance.
3. Iron deficiency anemia: After postpartum hemorrhage, especially if transfusions have been required, anemia can be profound and iron stores can become very depleted. This patient has a poor diet and is not taking any iron supplements; her fatigue, poor concentration, and dizziness could indeed be due in part to iron deficiency anemia. However, her symptoms of hypopituitarism should be addressed first.

Diagnostic studies

• Serum cortisol, ACTH: tests for ACTH deficiency
• Estradiol, FSH, LH: tests for gonadotropin deficiency
• IGF-1: test for growth hormone deficiency
• TSH: to test for hypothyroidism
• CBC, MCV, MCH: Low hemoglobin is a criterion for anemia. Hypochromic, microcytic anemia would suggest iron deficiency anemia.
• Serum electrolytes, glucose: Hypoglycemia and hyponatremia are symptoms of ACTH deficiency.
• MRI brain: imaging modality of choice in Sheehan syndrome, although imaging would likely only follow hormone studies if they are abnormal

Other differential diagnoses to consider

• Postpartum thyroiditis (subacute lymphocytic thyroiditis)
• Pituitary adenoma
• Adrenal insufficiency