Fatigue History-Case 1
Fatigue History-Case 1
Please assess the student as they take the following patient history:
Student's Email

CASE - The evaluating student should read the following case and role-play for their peer

 Dear Student: The following exercise is meant to be done as a role-play.  One student should read the case and role-play the patient.  The other student should act as the physician, and should not read the case or the checklist in advance. A third student, or the "patient", should complete the checklist during the interview to track their peer's progress.

 

Case:  Ms. FD

You are Mr. FD, a 24 year-old man.  You are currently studying engineering at the University of Toronto and live at home with your parents.  You are going to see your doctor because you have felt very exhausted over the last 3 weeks.

 

Three weeks ago, you started feeling tired all the time.  You can’t pinpoint any moment during which the fatigue started, but feel it began around the time that you broke up with your girlfriend of 1 year.  You feel tired all the time and have not been able to regain your energy, despite the fact that you have been sleeping 14 hours every night and participating in much fewer activities during the day.  The fatigue has not gotten any better or worse during the three weeks and you do not notice any changes in your energy level throughout the day.  Your appetite has also reduced; you attribute this to a loss of interest in eating more than any nausea or bothersome GI symptoms.

 

Since your fatigue started, you have stopped going to school.  You feel unable to find the energy to go and have lost interest in what you are learning.  You also feels that going to school is futile since you are having trouble concentrating for long enough to complete your assignments anyway.  

 

You were in good health prior to 3 weeks ago.  You are generally very active, playing soccer and basketball in recreational leagues regularly.  You do not smoke cigarettes.  You have 5-6 drinks socially on the weekends.   You are on no medications and have no allergies.  You have never experienced anything like this before.  You are very frustrated and want your old life back.  You have never been diagnosed with any psychiatric illness, though your mother has suffered from depression in the past.

 

Depression(Major Depressive Episode): Depression is defined by the DSM-V as “5 or more of the following symptoms present most of the day, nearly every day, for at least 2 weeks (where one of the symptoms is either depressed mood or loss of interest/pleasure): depressed mood, loss of interest/pleasure in most/all activities, sleep changes, appetite/weight changes, psychomotor retardation/agitation, low energy, poor concentration, thoughts of guilt/worthlessness, recurrent thoughts of death/suicide.”  It is the most common psychiatric disorder in the general population, though it is thought that up to 2/3 of depressed individuals do not receive appropriate treatment.  For more information, see: http://www.canmat.org/resources/CANMAT%20Depression%20Guidelines%202009.pdf

 

INTRODUCTION - The student should perform the following:

Washes hands
       
Introduces self
       

IDENTIFYING DATA- The student should inquire about the following:

Name of patient
       
Age of patient
       

CHIEF CONCERN- The student should inquire about the following:

Nature of concern
       
Duration of concern
       

HISTORY OF PRESENT ILLNESS- The student should inquire about the following:

Fatigue

Onset of fatigue
               
Alleviating factors of fatigue
               
Exacerbating factors of fatigue
               
Quality of fatigue
               
Severity of fatigue
               
Timing of fatigue
               
Course and progression of fatigue
               

General Questions

Associated symptoms
               
Previous similar episodes (includes: investigations related to these episodes)
               
Impact on quality of life and work performance
               

PERTINENT POSITIVES AND NEGATIVES - The student should inquire about the following:

Constitutional/General Symptoms

(Differential diagnosis includes: infection, malignancy, sleep apnea)

Weight change
       
Fever
       
Change in appetite
       
Recent exposures to new environment or infected individuals
       
Snoring

Sleep apnea is associated with fatigue.

       

Psychiatric Symptoms

(Differential diagnosis includes: depression, sleep disorder, stress)

Low mood
       
Sleep changes
       
Loss of interest
       
Feelings of guilt/worthlessness
       
Reduced cognition/difficulty concentrating
       
Nervousness/anxiety
       
Thoughts of suicide or homicide
       
Recent major changes in life/major stressors
       
Personal or family history of depression or other mental illness
               

Endocrine Symptoms

(Differential diagnosis includes: hypothyroidism, other endocrine disorders)

Cold intolerance
       
cognitive dysfunction
       
Constipation or diarrhea
       
Dry skin
       
Changes in hair texture
       
Masses in neck
       
Pain in neck
       
Changes in swallowing
       
Personal or family history of endocrine disorder
               

Nutrition-related Symptoms

(Differential diagnosis includes: anemia, other vitamin deficiency)

Weakness
               
Dyspnea
       
Headache
       
Palpitations
       
Pallor
       
Dizziness/syncope
       
Hair/nail changes
       
Eat ice (PICA)
       
Everyday diet
               

MEDICATIONS AND ALLERGIES- The student should inquire about the following:

Medications (includes: prescription, over-the-counter, and herbal/alternative medicines)

Medication errors can be a serious cause of fatigue, so it is important to ensure that the patient is taking their medications correctly and that they have been assigned proper medications.

               
Allergies to drugs or otherwise (includes: nature of reaction, timing of reaction, formal testing performed)
               

PAST MEDICAL HISTORY - The student should inquire about the following:

It is important to ask about diagnosed medical illnesses, surgeries, hospitalizations, and immunization history.  However, all relevant aspects of Past Medical History have been covered in the pertinent positives/negatives section.

SOCIAL HISTORY AND HABITS - The student should inquire about the following:

 

Smoking (includes: pack years; if they quit, when)
               
Alcohol (includes: quantify)
               
Drugs (includes: types, frequency of use, quantity, methods)
               
Living arrangement
               
Relationships & Children
               
Hobbies & Interests
               
Occupation
               

REVIEW OF SYSTEMS- The student should inquire about the following:

Though it is important to perform a thorough review of systems when seeing patients, this is not relevant for this case.