Case 29: Fatigue

Opening scenario

Lisa Perez, an 18-year-old female, comes to the physician's office because of fatigue.

Vital signs

• Temperature: 97.7°F (36.5°C)
• Blood pressure: 110/80 mm Hg
• Heart rate: 64/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

• You are not aware of the meanings of medical terms (e.g., monospot test) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Is this something you are experienced in treating? Do a lot of patients my age have problems like this?”

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 feel really exhausted. I just do not have the energy I used to have.
• Onset
• It started about 2 weeks ago.
• Constant/intermittent
• All the time.
• Precipitating events
• I had a fever and a sore throat 2 weeks ago. I took some ibuprofen for it, and it went away after a couple of days, so I did not bother going to the doctor. Since then I have just been totally worn out.
• Progression
• I have been exhausted the whole time.
• Previous episodes
• Never.
• Alleviating factors
• None, unfortunately.
• Aggravating factors
• None.
• Associated symptoms
• No.

Review of systems specific to fatigue

• Swelling of the ankles
• No.
• Fever/chills
• Not since my sore throat 2 weeks ago.
• Racing of the heart
• No.
• Rash/skin changes
• No.
• Chest pain
• No.
• Shortness of breath
• No.
• Bowel problems
• No.
• Sleep problems
• Well, I sleep more than I used to. But even with more sleep, I feel tired all day.
• Appetite
• Normal.
• Weight changes
• No.
• Cold intolerance
• No.
• Hair changes
• No.
• Voice changes
• No.
• Muscle cramps
• No.
• Mood
• I feel tired, but not sad.
  • Loss of interest
  • No.
  • Guilt/low self-esteem
  • Sometimes I have self-doubts because of how I look, but normally I'm quite okay with myself.
  • Low energy
  • Yes. I feel really tired and exhausted.
  • Poor concentration
  • Yes, I am just too tired to think.
  • Psychomotor agitation or retardation
  • No.
  • Suicidality
  • No, thank god, I would never kill myself. I have also never thought about this before.
  • Social support
  • My friends are great and always there for me.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• None.
• Hospitalizations
• Never.
• Ill contacts
• One of my roommates was sick 2 weeks ago as well. She had a sore throat and a fever.
• Past surgical history
• None.
• Family history
• My mom has some kind of thyroid problem.
• Work
• I study economics at the local college.
• Home
• I live in an apartment with two of my friends.
• Alcohol
• Maybe 3–4 cocktails on the weekend. I do not drink during the week.
• Recreational drugs
• Never.
• Tobacco
• No.
• Exercise
• Oh yeah, I love to exercise. I play basketball on my college team. But I have been so tired lately that I have not been able to go to practice. I really miss it.

Sexual history, OB/Gyn

• Sexually active
• Yes.
• With whom
• With my boyfriend.
• Men or women
• Only men.
• Number of partners over the past year
• I have had 2 sexual partners.
• Protection
• We have always used condoms.
• Last menstrual period
• 2 weeks ago.
• Menarche
• I was 14 years old.
• Duration of period
• About 8 days.
• Period regular
• Yes.
• How many tampons per day
• I feel like my periods are heavier than what my friends have. I have to use the biggest tampon size and change it every 2 hours or so.
• Pregnancies
• No.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the conjunctivae
  • Inspection of the oropharynx
• Neck examination
  • Inspection of the neck
  • Palpation of the lymph nodes of the head and neck
  • Examination of the thyroid gland
• Abdominal examination
  • Palpation of the liver
  • Palpation of the spleen
• Extremities
  • Inspection of the lower extremities
• Skin examination
• Neurologic examination
  • 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 avoidance of contact sports in suspected mononucleosis.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Perez, I can understand your concern. Fatigue is actually not an uncommon problem. We have a lot of patients who come to us because they are exhausted just like you – including patients in your age group. Based on what you have told me today, your fatigue could be due to an infection, a problem with your thyroid gland, a lack of iron in your blood, or a few other possible diagnoses. To find out exactly what is going on, I would like to run some tests. I can assure you that you are in good hands and will be taken care of very well here. What do you think about that?”

In infectious mononucleosis, splenomegaly can lead to potentially life-threatening splenic rupture! Patients should be advised to avoid any physical activity that could trigger splenic rupture (e.g., contact sports) for at least 3 weeks after the onset of symptoms.

Patient note

Differential diagnoses

1. Infectious mononucleosis: A history of a sore throat and flu-like symptoms followed by fatigue in a teenager or young adult should always raise concern for infectious mononucleosis. Given the absence of findings of other differential diagnoses (e.g., anemia) and the fact that this patient's roommate had similar symptoms 2 weeks ago, infectious mononucleosis is the most likely diagnosis. It is very important to counsel all patients with suspected mononucleosis to avoid physical activity that may trigger splenic rupture (e.g., contact sports) for at least 3 weeks after the onset of symptoms.
2. Iron deficiency anemia: Iron deficiency anemia is the most common cause of anemia and particularly affects young women with significant menstrual blood loss, such as this patient. While it can also present with severe fatigue, the onset is usually slower than seen here. Additionally, this patient's recent history of sore throat and fever make infectious mononucleosis more likely.
3. Hypothyroidism: Hypothyroidism can present with fatigue and loss of concentration, and this patient has a family history of thyroid disease. However, the onset is usually less acute, and other symptoms such as cold intolerance are often present. Although hypothyroidism should certainly be excluded in this case, this patient's menorrhagia and sore throat make the other two differential diagnoses more likely.

Diagnostic studies

• Monospot test: detects heterophile antibodies produced in response to EBV infection
• LDH, AST, ALT: to assess for hepatic involvement in infectious mononucleosis
• CBC and peripheral smear: to assess for microcytic, hypochromic anemia, which is a sign of iron deficiency anemia. Peripheral smear shows lymphocytosis with > 10% atypical lymphocytes in infectious mononucleosis.
• Serum iron, ferritin, transferrin, total iron binding capacity (TIBC): Would show ↓ serum iron and ferritin, and ↑ serum transferrin and total iron binding capacity in iron deficiency anemia.
• TSH, FT3, FT4: to assess for hypothyroidism

Other differential diagnoses to consider

• Major depressive disorder
• Acute HIV infection (acute retroviral syndrome)
• CMV infection
• Viral hepatitis (e.g., hepatitis B, hepatitis C)