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Fatigue Case Study

Fatigue Case Study

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

References

Buysse  DJ. Insomnia. JAMA. 2013;309:706–16.

Doghramji  K. The evaluation and management of insomnia. Clin Chest Med. 2010;31:327–39.

Fatigue. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 3e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=1088§ionid=61698761. Accessed November 03, 2017.

Falloon  K, Arroll  B, Elley  CR, Fernando  A  3rd The assessment and management of insomnia in primary care. BMJ. 2011;342:d2899.

McDermott  MT. In the Clinic. Hypothyroidism. Ann Intern Med. 2009;151:ITC61.

Liver Function Tests: MedlinePlus. (n.d.). Retrieved November 03, 2017, from https://medlineplus.gov/liverfunctiontests.html

Lurie  A. Obstructive sleep apnea in adults: epidemiology, clinical presentation, and treatment options. Adv Cardiol. 2011;46:1–42.

Myers  KA, Mrkobrada  M, Simel  DL. Does this patient have obstructive sleep apnea? JAMA. 2013;310:731–41.

Neubauer  DN. Insomnia. Prim Care. 2005;32:375–88.

NBME, www.nbme.org/pdf/SubjectExams/LabReferenceValues.pdf Retrieved November 3, 2017, from www.nbme.org/pdf/SubjectExams/LabReferenceValues.pdf.

Physical Exam Section Words And Transcription Examples For Medical Transcriptionists. (n.d.). Retrieved November 03, 2017, from http://www.medicaltranscriptionwordhelp.com/pe-section-examples-for-medical-transcriptionists

Ramachandran  SK, Josephs  LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology. 2009;110:928–39.

Rondondi  N, den Elzen  WP, Bauer  DC  et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010;304:1365–74.

Sateia  MJ, Nowell  PD. Insomnia. Lancet. 2004;364:1959–73.

Silber  MH. Chronic insomnia. N Engl J Med. 2005;353:803–10.

Wilson  JF. In the Clinic. Insomnia. Ann Intern Med. 2008;148:ITC13-1–ITC13–16.

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.

 

 

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