42 A 45-Year-Old Female With Fatigue and Headache


Case 42

A 45-Year-Old Female With Fatigue and Headache



Rachel Ramirez



A 45-year-old female presents to the office as a new patient to establish primary care after switching insurance plans. Her biggest concern is fatigue, which she has been experiencing for the past several months.



How should you begin to evaluate fatigue?


A good way to evaluate fatigue is to first establish its timing or chronicity. Is the fatigue of recent onset (i.e., in the past few days)? Or has it been present for weeks to months? As you take the patient’s history, it is important to use open-ended questions and clarifying statements such as “What is it that you mean when you say ‘I’m feeling tired’?” or “Describe for me the fatigue you feel.”


Additional history gathering should include the following:



The differential diagnosis for fatigue is very broad, and the etiology is often multifactorial (see Table 42.1).



On further questioning, the patient reveals that her fatigue has been progressively worsening. It is present each day to varying degrees, depending on the day’s activities. She is able to commute to work and back but she no longer goes to the park with her children and dog. The patient also notes shortness of breath and a feeling of her heart pounding in her chest when she climbs stairs. She complains of an intermittent headache that is dull, diffuse, and pounding with no preceding aura. It resolves with over-the-counter acetaminophen or ibuprofen.


When asked about her past medical history, the patient recalls being told she has fibroids in her uterus. Her surgical history includes a caesarian section for the birth of her only child.


The patient is married and works in real estate part time. She lives at home with her husband, her biological son, two stepsons, and a dog. She has never used tobacco; she drinks a glass of wine once a week and has never used illicit drugs. She eats an average American diet that includes meat and vegetables. She does not specifically avoid any items.


In addition, the patient reveals that she has been told by her dentist that she has “terrible enamel” and admits to having a craving for ice all the time and chewing it throughout the day. You note no neck swelling or symptoms of adenopathy and no rashes. Her weight is stable, and she denies dark or bloody stools, abdominal pain, nausea or vomiting. She has no swallowing complaints. Her nails are thin and break easily. Her menstrual periods are heavy and long lasting, with her cycles falling between 28 and 30 days. She has painful cramps that sometimes limit her ability to work on the first day of her menses. She soaks up to eight pads a day and has to “double up” at night.


She has no musculoskeletal complaints, nor other neurologic complaints. She has no urinary tract complaints.



TABLE 42.1


Differential Diagnosis of Fatigue*


Type


Sleep Disorders:


Sleep apnea, insufficient sleep syndrome, insomnia


Infections (Both Acute and Chronic Infections):


Bacterial infections, mononucleosis, hepatitis, and HIV


Malignancy


Psychologic Illness:


Depression, anxiety


Chronic Autoimmune Illnesses:


Rheumatoid arthritis, lupus, scleroderma, systemic vasculitis


Endocrine/Metabolic Disorders:


Hypothyroidism, diabetes mellitus type 1 and 2, adrenal dysfunction, electrolyte abnormalities


Drugs and Medications:


Antidepressants, muscle relaxants, opiate drugs, antipsychotic drugs


Anemia


Iron deficiency anemia, thalassemia, anemia of chronic disease, B12 deficiency



*This list is by no means everything—there are so many different causes—this is just a glimpse of some common causes.


CHF, Congestive heart failure; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; ILD, interstitial lung disease.


(Modified from Seller RH, Symons AB. Differential Diagnosis of Common Complaints. 6th ed. Philadelphia: Elsevier; 2011.)



What are the key elements to this patient’s fatigue history that help narrow down the differential diagnosis? What questions do you want to ask further?


The patient’s history reveals a number of important elements:



• “Progressive and daily”: This suggests the fatigue is not resolving on its own.


• “Depending on activities”: This prompts the clinician to inquire, “What activities make it worse?”


• “No longer does [physical activity]”: This may mean the fatigue is exertional fatigue.


• “Shortness of breath”: This suggests pulmonary symptoms, prompting the clinician to ask “Is there cough? Do you have chest tightness? Do you have trouble breathing when at rest? Do you have trouble breathing when laying down flat? Do you have to take many deep breaths or are your breaths small and rapid?”


• Cough would aim toward an alveolar or infiltrative process.


• Tightness may indicate bronchoconstriction as in asthma.


• Breathlessness at rest can be a sign of severe congestive heart failure.


• Breathlessness when recumbent can be a sign of congestive heart failure, pericardial effusion, pleural effusion, or compression by a neoplasm.


• The timing and depth of breathing can indicate infiltrative process such as interstitial lung disease (rapid shallow breathing) or physical deconditioning (deep breathing).


• “Heart pounding”: This suggests cardiovascular effects, prompting the clinician to ask “Is it a regular or irregular pounding?”


• Regular rhythm that is rapid (tachycardia) can indicate supraventricular tachycardia or atrial tachycardia.


• Irregular heart rhythm may be atrial fibrillation, atrial flutter, or premature ventricular contractions.


• “Headache”: The differential for headache is broad and diverse. However, in the context of fatigue, shortness of breath, absence of focality or classic migraine pattern, a primary neurologic finding is unlikely.


The patient provides a tremendous amount of information that can help narrow down the differential. Of the above history, a few key phrases can direct us toward the diagnosis:




On physical exam, the blood pressure is 90/58 mm Hg, her pulse rate is 88/min, respiration rate is 16/min, and the body mass index (BMI) is 23.38 kg/m2. In general, she is a well-developed, well-nourished African American female showing no distress.


She has pale conjunctivae and pale sublingual mucosa. Her thyroid is normal in size and texture and she has no lymphadenopathy. Her cardiopulmonary exam is normal. Her abdomen has normal active bowel sounds and is soft and nontender. A firm, nontender mass is appreciated in the left lower quadrant. Her pelvic exam reveals normal external genitalia with no vaginal or cervical discharge. A bimanual exam reveals an enlarged, nontender uterus. Her ovaries are not palpated and no cervical motion tenderness is noted. Her rectal exam reveals a normal sphincter tone and brown stool negative for occult blood. Her neurologic exam reveals that her cranial nerves are intact, her reflexes are symmetric, and strength and gross sensory testing are normal. The patient possesses normal insight, orientation, judgment, and thought processes. The results of laboratory testing are shown in Table 42.2 and Table 42.3. The peripheral blood smear is reviewed and pictured in Figure 42.1.




TABLE 42.3


Patient’s Complete Blood Count




















































Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. 14 A 60-Year-Old Male With Acute Headache and Fever
  2. 12 A 68-Year-Old Male With Weakness and Fatigue
  3. 23 A 58-Year-Old Female With Dyspnea on Exertion and Renal Failure
  4. 53 A 57-Year-Old Female With Cavitary Lung Lesions

Stay updated, free articles. Join our Telegram channel

Tags:
Jun 15, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 42 A 45-Year-Old Female With Fatigue and Headache

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access
Name Value Reference Range
White blood cells 4.1 4.0-12.0 k/µL
Red blood corpuscles 3.66 4.2-5.4 M/µL
Hemoglobin 5.3 12.0-16.0 g/dL
Hematocrit 18.9 37-47%
Mean corpuscular volume 51.5 81-99 fL
Mean corpuscular hemoglobin concentration 28.1 32-36%
Red cell distribution width 28.9 11.5-15%
Platelet 192 140-400 k/µL
Mean platelet volume 10.1 7.4-10.4 fL
Neutrophils 61 %
Lymphocytes 33 %