Fatigue History-Case 2
Fatigue History-Case 2
Please assess the student as they take the following 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. FR

You are Ms. FR, an 18 year-old woman.  You are currently studying criminology at Ryerson University and live with a roommate in downtown Toronto.  You are going to see the doctor because you have felt very fatigued, on and off, over the last 4 months.

 

For the past 4 months, you have felt general fatigue beyond what you expect as a busy university student.  You notice the fatigue some mornings when you wake up feeling as if you have not rested at all.  You also get tired much more quickly when participating in recreational hockey and basketball at school.  You have 1-2 bad mornings per week and find that they tend to cluster together during your menstrual period.  Similarly, you find yourself especially tired when you exercise during your period.  During your episodes of fatigue, you either rest, ignore it, or try to combat the fatigue by drinking more coffee; you find that none of these interventions seem to help much.  You have no symptoms associated with your fatigue that you can pinpoint.        

 

You are an active person who spends your time outside of school watching Netflix and playing recreational sports.  Since starting university 8 months ago, you decided to become a vegetarian.  This is something you’ve always wanted to do but were unable to while you were living at home with your parents.  While you find the fatigue tolerable, you are beginning to feel frustrated by your lack of energy.  You are looking for advice about what sort of lifestyle changes you can make to manage your fatigue better.  You have never experienced anything like this before.

 

You take no medications and have no allergies.  You do not smoke cigarettes and consume 1-2 alcoholic beverages on the weekend with friends.

 

Iron-Deficiency Anemia:  Iron-deficiency anemia refers to a decrease in red blood cell mass corresponding to a Hb<130g/L/Hct <0.41 (males) or Hb <120g.L/Hct <0.36 (females).  The condition occurs due to an increased demand for iron (e.g. pregnancy), decreased supply of iron (e.g. dietary deficiencies/malabsorption), or increased loss of iron (e.g. hemorrhage, hemolysis).  While menstrual blood loss is the most common cause in pre-menopausal women, blood loss from the GI tract is the most common cause in adult men and post-menopausal women.  For more information, see: http://www.bcguidelines.ca/pdf/iron_deficiency.pdf.

INTRODUCTION - The student should perform the following:

Washes hands
       
Introduces self to patient
       

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
       
Any chance of pregnancy
       
Personal or family history of bleeding disorder or GI malignancy
               
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
       
Changes in menstrual cycle
       
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
       
Changes in bowel habits

Celiac disease can contribute to the development of iron-deficiency anemia, largely due to defects in absorption of dietary iron.  Blood loss may/may not play a role as well.

               
Changes in menstrual cycle

Menstrual losses account for a significant monthly blood loss, predisposing pre-menopausal women to iron-deficiency.

               
Hair/nail changes
       
Eat ice (PICA)

Pica is a disorder characterized by an appetite for non-food items such as clay or dirt; it is often associated with nutrient deficiencies.  Pagophagia describes pica for ice, specifically; it is the form of pica associated with iron-deficiency anemia.

       
Everyday diet

Calcium and soy protein interferes with iron absorption from the gut and can thus lower someone’s iron stores; high iron foods such as meat, fish, poultry, dried beans, and lentils are effective at restoring the body’s iron stores.

               

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.  It is also important to ask about ASA/NSAID use as these drugs may increase the risk of a GI bleed.

               
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.