CASE 27 - Fatigue

Question 1

I want to go on a trip with my wife. Can we do the tests after I come back?

Answer 1

It doesn’t sound as though you’re feeling well enough to be able to enjoy a trip.

Let’s do some initial blood tests, and then we can see how you’re feeling and decide whether we’re comfortable letting you go away.

Question 2

Specific Qs:

Answer 2

1. Progression of the fatigue during the day?
2. Affecting job/performance?
3. Feeling of depression.
4. Reason for feeling sad.
5. Suicidal thoughts/plans/attempts.
6. Feelings of blame, guilt, worthlessness.
7. LoC + LoI.

Question 3

PEx:

Answer 3

1. Head and neck exam ==> Inspected conjunctivae, mouth and throat, lymph nodes; examined thyroid glands.
2. CV ==> A.
3. Chest ==> A.
4. Abdo ==> A + P + P (including rebound tenderness and Murphy’s sign).
5. Extr ==> I + P.

Question 4

DDx:

Answer 4

1. Pancreatic cancer.
2. Depression.
3. Chronic pancreatitis.
4. PUD.
5. Hypothyroidism.
6. See diagram.

Question 5

Workup:

Answer 5

1. CBC, stool for occult blood.
2. Glucose.
3. Fecal fat studies.
4. Amylase, lipase.
5. AST/ALT/bil (direct, indirect, and total)/ALP.
6. CT-abdomen.
7. TSH.
8. Beck depression inventory.