Case 36: Fatigue

Opening scenario

Nick Booker, a 54-year-old male, comes to the physician because of fatigue.

Vital signs

• Temperature: 98.5°F (36.9°C)
• Blood pressure: 130/80 mm Hg
• Heart rate: 70/min
• Respirations: 17/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

• When the examinee inspects your eyes, show the following image.
• When the examinee presses on the upper right part of your abdomen, say that you have mild pain there.
• You are not aware of the meanings of medical terms (e.g., ultrasound) 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 should get an HIV test?”

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 feeling really tired lately.
• Onset
• About 4 weeks ago.
• Constant/intermittent
• Pretty much all the time.
• Precipitating events
• I think I had the stomach flu about a week before the fatigue started. I had fever and threw up a lot; I could not eat anything for almost a whole week.
• Progression
• I think the stomach flu is pretty much gone. But the fatigue just seems to be getting worse.
• Previous episodes
• Not like this.
• Alleviating factors
• Well, I guess sleep helps a little.
• Aggravating factors
• I think drinking alcohol probably does not really help.
• Associated symptoms
• My muscles also started hurting around the same time. You know, sort of like when you have a cold?

Review of systems specific to fatigue following fever and vomiting

• Recent travel
• No.
• Nausea/vomiting
• I am still a little nauseous, particularly in the mornings.
• Fever/chills
• No.
• Night sweats
• No.
• Rash/skin changes
• No.
• Pain in joints
• No, just in my muscles.
• Urinary problems/changes in urine color
• No.
• Bowel problems/changes in stool color
• Yes, my stools have looked kind of light lately.
  • Abdominal pain
  • Yes, on the right side, right under my ribs.
• Appetite
• I have not had much of an appetite the past two months.
• Weight changes
• Yes, I have lost about 10 lbs over the past 2 months. But I think it started before I had any of the symptoms I have now.
• Pruritus
• Yes, for the past few days.
• Breast swelling
• No.
• Decreased body hair
• No.
• Decreased sex drive
• It is not that I do not want to, it's just that I have not been in a relationship since my divorce 7 years ago.

Past medical history, family history, and social history

• Past medical history
• I have had two episodes of pancreatitis. One about 5 years ago and the other last year.
• Allergies
• None.
• Medications
• None.
• Hospitalizations
• I had to go to the hospital the last time I had pancreatitis.
• Ill contacts
• No.
• Past surgical history
• None.
• Family history
• I don't know – I was adopted.
• Work
• I used to work at a restaurant, but I lost my job last year.
• Home
• I live by myself.
• Alcohol
• I drink about 10 beers a day.
  • Felt need to cut down on your drinking?
  • Yes, it is pretty much what ruined my marriage. But I think it is just too late to stop now.
  • Felt annoyed by people criticizing your drinking?
  • Sure, stopping is just easier said than done.
  • Felt guilty about drinking?
  • Yes.
  • Felt the need to drink first thing in the morning?
  • Almost every day.
• Recreational drugs
• I have used cocaine on and off for the past 10 years, and I tried heroin for the first time about 3 months ago and have been using pretty much every day since.
  • Intravenous drug use
  • I used to snort the cocaine, but 3 months ago I started to inject cocaine and heroin.
• Tobacco
• I have smoked about a pack a day for the past 35 years.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the sclera
    • Show the examinee this image:
• Chest examination
  • Inspection of the chest
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
  • Palpation of the liver
    • Mild tenderness to palpation
  • Palpation of the spleen
  • Shifting dullness
• Extremities
  • Inspection of the hands
  • Inspection of the lower extremities

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 did not repeat painful maneuvers during physical examination.
• 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 illicit drugs.
• Examinee offered counseling on alcohol abuse.
• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Booker, I understand your concern that you might have HIV. Although your current symptoms could be due to a variety of causes, your history of intravenous drug use is a risk factor for HIV infection, and I would recommend getting tested for HIV at this time if you agree. If you are interested, I would also like to get you in touch with our social worker, who can help you find some rehab programs. I would also like to strongly caution you not to share needles or syringes with other people, because doing so puts you at risk for infection with HIV, hepatitis C, and other life-threatening diseases.”

Patient note

Differential diagnoses

1. Acute hepatitis B and/or C infection: This patient is an injection drug user, which puts him at increased risk for infection with hepatitis B and hepatitis C. Acute viral hepatitis is frequently asymptomatic. When present, symptoms closely resemble those of this patient, including an initial flu-like illness with gastrointestinal complaints (nausea and vomiting), followed by a protracted stage of decreased appetite, RUQ abdominal pain, and persistent fatigue. In addition, intrahepatic cholestasis and subsequent hyperbilirubinemia (e.g., scleral icterus) may occur, as in this case.
2. Alcoholic hepatitis: Alcoholic hepatitis is also a plausible differential diagnosis for a patient with alcohol use disorder and nonspecific symptoms of mild nausea, loss of appetite, and weight loss. RUQ pain from hepatic tenderness can also be present in alcoholic hepatitis, as can scleral icterus and other symptoms of intrahepatic cholestasis (e.g., pale stools). However, alcoholic hepatitis would not account for this patient's initial bout of flu-like symptoms and gastrointestinal complaints, which are more typical of an acute infection (i.e., viral hepatitis). Moreover, he does not have hepatosplenomegaly, ascites, or any cutaneous signs of liver disease, all of which would make alcoholic hepatitis more likely.
3. Pancreatic cancer: A careful review of this patient's history reveals decreased appetite and weight loss starting 2 months ago, prior to the episode of flu-like symptoms and gastrointestinal complaints. These symptoms, along with his scleral icterus, pruritus, and pale stools (i.e., symptoms of cholestasis) should raise concern for pancreatic cancer and resulting extrahepatic cholestasis, for which he also has several risk factors: a history of pancreatitis, alcohol use disorder, and smoking. However, his abdominal pain is localized to the RUQ (i.e., the liver), whereas the pain of pancreatic cancer tends to be epigastric pain that radiates along the belt line, around the trunk and to the back. In addition, the Courvoisier sign is not present, making an inflammatory or infectious process more likely than a neoplastic one.

Diagnostic studies

• Abdominal ultrasound: Liver tissue can appear abnormal in acute hepatitis A, hepatitis B, hepatitis C, and alcoholic hepatitis. A pancreatic mass and resulting cholestasis can be visualized on ultrasound in pancreatic cancer.
• Abdominal CT with contrast: If pancreatic cancer is suspected and a pancreatic mass visualized on ultrasound, CT is usually performed. Findings suggestive of pancreatic cancer on CT include a poorly defined, hypodense/hypoechoic, and hypovascular mass with the double-duct sign (blockage and dilation of both the common bile duct and the pancreatic duct. )
• CBC: Macrocytic anemia, thrombocytosis or thrombocytopenia, and absolute neutrophilic leukocytosis may be present in alcoholic hepatitis and cirrhosis.
• PT, PTT: to assess for impaired hepatic synthesis (e.g., due to cirrhosis)
• AST, ALT, bilirubin, alkaline phosphatase, GGT, lipase: An AST/ALT ratio > 1 indicates liver cell damage, as in alcoholic hepatitis. In acute hepatitis A, hepatitis B, and hepatitis C, serum transaminase levels are also highly elevated, but, unlike in alcoholic hepatitis, ALT levels are greater than AST levels (the AST/ALT ratio is usually < 1). Elevated bilirubin, alkaline phosphatase, and GGT indicate cholestasis, which can occur extrahepatically in pancreatic cancer but also in viral hepatitis and alcoholic hepatitis. Lipase is elevated in pancreatitis and pancreatic cancer.
• Albumin: to assess for impaired hepatic synthesis (e.g., due to cirrhosis)
• Hepatitis viral serology (HAV, HBV, HCV): Elevated anti-HAV IgM confirms acute hepatitis A infection. Testing for HBsAg and anti-HCV antibodies is used to screen for hepatitis B and hepatitis C.
• HIV testing: The patient has never had an HIV test and is part of a high-risk group.

Other differential diagnoses to consider

• Cirrhosis
• Chronic pancreatitis
• Choledocholithiasis
• Cholangiocarcinoma
• See also jaundice and cholestasis.