Fatigue
Mrs. M is a 42-year-old woman who has had fatigue for the past 6 months. Mrs. M reports that she is tired all the time, beginning first thing in the morning and lasting all day. She also reports frontal headaches several mornings per week, intermittent lower abdominal pain relieved by bowel movements, and low back pain. She does not complain of any trouble sleeping.
Her past medical history is notable for menorrhagia and iron deficiency anemia when she was in her 20s and is otherwise unremarkable. Currently, her menses occur every 30 days, with bleeding for 3–4 days. Her family history is notable for thyroid disease in her mother and breast cancer in her paternal grandmother.
She takes no medications, does not smoke, and does not drink alcohol. She has never used illicit drugs. She works as a teacher, and her husband is a security guard. They have 2 children, ages 9 and 12. She does not report any recent changes at home or work. Mrs. M does not lack interest in her usual activities or feel depressed. She has not lost or gained weight. She worries about money and her family but has never had a panic attack and does not consider herself excessively nervous or anxious.
On physical exam, she appears healthy and her affect is normal. Her BMI is 35. HEENT exam is normal. There is no thyromegaly or adenopathy. Lungs are clear. There are no breast masses. Cardiac and abdominal exams are normal, and there is no edema. Her CBC, glucose, electrolytes, BUN, creatinine, liver function tests, and TSH are all normal. Mrs. M does not meet DSM criteria for anxiety or depression. It is therefore necessary to consider the alternative diagnoses.
Mrs. M works as a teacher, rising at 6 am, leaving her house at 7 am, and returning home about 5 pm. She then prepares dinner for her family, helps her 2 children with their homework, and grades papers until 9:30 pm. She watches a little television, and then goes to sleep about 10:00 pm. Her husband works from 3 pm to 11 pm, and she often wakes up when he gets home at midnight. He needs some time to “wind down” before he goes to sleep, so they often talk and watch TV in bed for an hour or so. After her husband dozes off, she often cannot fall back asleep, and will sit in bed “surfing” the Internet on her laptop for an hour or two. She also comments that she feels tired even when she sleeps straight through the night on the weekends, and her husband complains about her snoring.Mrs. M is reassured that her laboratory tests are normal. A polysomnogram shows an AHI of 2 when she sleeps on her side, and an AHI of 15 when she is on her back. After listening to you explain the principles of sleep hygiene, she decides to talk with her husband about ways they could spend time together without interrupting her sleep so often. Since she has an elevated AHI only when she is supine, you recommend that she wear a backpack or use special pillows to help her stay on her side during sleep.
When she returns 6 months later, she reports that she is still tired because she values the time she spends with her husband at night. However, she now asks him to sleep in the guest room when she feels exceptionally fatigued, so she can have a few nights of uninterrupted sleep. She is successfully using a body pillow to stay on her side at night. She has also found that a 15-minute nap at lunchtime helps.
SOAP Note
S-Mrs. M is a 42-year-old woman seeks treatment now for chronic, unrelenting fatigue starting 6 months ago. Fatigue persists even when patient has had full night of sleep and worsens upon stimulation while sleeping with weekly acute a.m. headaches, sleep apnea, and abdominal/lower back pain relieved with bowel movements. Mrs. M has a past medical history of menorrhagia and anemia with a family history of thyroid disease. She denies any changes in appetite or weight, anxiety attacks, trouble sleeping, any drug/alcohol use, changes in life events, lack of interest in activity, depression.
O- physical exam, she appears healthy and her affect is normal. Mrs. M does not meet DSM criteria for anxiety or depression. But does note that she worries about money.
BMI=35 (obese)
Lungs= clear apices to bases bilaterally without wheezes, crackles or rhonchi
Heart: Rhythmic and regular. No gallops, rubs, or murmurs noted.
HEENT: Head is normocephalic and atraumatic. Nares are patent. Nasal mucosa is normal. PERRLA. Extraocular muscles are intact. No nystagmus. Oral mucosa moist and pink without erythema or exudate.
Skin: Soft, thick, warm and dry. Good turgor. Natural in color. No edema noted.
Neck: Thyroid is midline and nonnodular. Trachea is midline. No carotid bruits noted on auscultation. No lymphadenopathy noted.
Breast: Symmetric. No masses. No pain. No discharge. No axillary node.
Abdomen: Soft and tender. Positive Bowel sounds.
Labs
AHI: 2 on side 15 supine
Alanine Transaminase (ALT): 7 to 56 U/L
Aspartate Transaminase (AST): 10 to 40 U/L
Alkaline Phosphatase (ALP): 45–115 U/L
Albumin: 3.5–5.0 g/dL
Bilirubin: 0.1–1.2 mg/dL
BUN: Blood urea nitrogen, serum or plasma 7-20 mg/dL
CBC:
Erythrocyte count: Female: 3.5-5.5 million/mm3
Erythrocyte sedimentation rate (Westergren): Female: 0-20 mm/h
Hematocrit: Female: 36%-46%
Hemoglobin, blood: Female: 12.0-16.0 g/dL
Hemoglobin, plasma: 1-4 mg/dL
Leukocyte count: 4500-11,000/mm
Segmented neutrophils 54%-62%
Bands 3%-5% Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count: 0.5%-1.5%
Thrombin time <2 seconds
Glucose, serum: Fasting: 70-110 mg/dL
2-h postprandial: < 120 mg/dL
Creatinine, serum: 0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na+) 136-145 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Chloride (Cl–) 95-105 mEq/L
Bicarbonate (HCO3–) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Iron, serum or plasma: 40–155 µg/dL
TSH: Thyroid-stimulating hormone, serum or plasma 0.5-5.0 μU/mL
A: Chronic Fatigue due to Obstructive Sleep Apnea
R/O: Chronic Fatigue due to poor sleep hygiene
R/O: Direct Insomnia
P: Continue telling husband not to interrupt when especially fatigued and using pillow/backpack to stay on side while sleeping. Continue 15 min. nap at lunchtime. Start weight loss plan to reduce BMI. Consider speaking with mental health professional to address sleep hygiene issues and money anxiety. Consider CPAP 4-20 cm H2O heated humidifier mask to fit mouth nightly when sleeping.
f/u in 1 month
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I learned a lot from my research on fatigue due to this assignment. Before this project, I had no idea that fatigue had such a high comorbidity with psychiatric disorders like depression or anxiety. Both patients and providers may have a tendency to see fatigue as more of a physical process without evaluating the extent to which our cognition plays a role. At least in Mrs. M’s case, her physical manifestation of fatigue alerted me (or a healthcare professional) to its primary source so that we can work together to treat her in a holistic manner.
