Fatigue History-Case 3
Fatigue History-Case 3
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:  Mrs. FH

You are Mrs. FH, a 43 year-old physician living in Toronto with your husband and two young children. You are going to the doctor because you have been experiencing fatigue for the last 2 months.


About 2 months ago, you noticed that you were more tired than usual.  Though you have been able to continue with your everyday life, you feel like your general stamina is reduced.  You have trouble getting up in the morning and are always ready to fall asleep at the end of the day.  You have not noticed any variation in your fatigue throughout the day, nor have you been able to identify anything that makes you more or less tired.  In addition to your fatigue, you have noticed that in the last month or so, you become cold more easily and have developed very dry skin.  Though your symptoms of fatigue have not been progressing, you are having more and more trouble coping with your everyday life; you would like to figure out the cause of your fatigue before it starts to become a considerable interference. 


You live a rather sedentary lifestyle, as you have trouble finding time to exercise between your busy job and busy kids.  You do not smoke cigarettes, drink alcohol, or use recreational drugs.  You are not on any medications.  As you are a practicing family physician, you have your suspicions about what is affecting you, but you wanted to see another physician to help confirm and manage your symptoms.



Hypothyroidism:  Hypothyroidism refers to a deficiency in thyroid hormone production at the level of the thyroid gland, either due to an underperforming gland or dysfunctional endocrine signaling throughout the body.  Hypothyroidism affects 2-3% of the adult population, with women 10x more likely to have the condition.  The clinical presentation of hypothyroidism is highly variable (depending on age of onset, duration/severity of deficiency), though common presenting symptoms include: fatigue, cold intolerance, weight gain, constipation, dry skin, myalgias, menstrual irregularities.  For more information, see: https://www.aace.com/files/final-file-hypo-guidelines.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:


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, pregnancy)

Weight change
Change in appetite
Recent exposures to new environment or infected individuals
Any chance of pregnancy

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
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)

Thyroid hormone has many diverse effects on the body, including regulation of basal metabolic rate, protein synthesis, and response to catecholamines.  Because of its broad affects on the body, changes in normal thyroid hormone homeostasis can lead to a variety of seemingly unrelated signs and symptoms as described here.

Cold intolerance
Constipation or diarrhea
Dry skin
Changes in hair texture
Changes in menstrual cycle
Masses in neck
Pain in neck
Changes in swallowing

Changes in swallowing, as well as neck pain/mass, can be caused by the formation of a goiter (enlarged thyroid glad), or other masses related to the presentation of hypothyroidism.

Personal or family history of endocrine/autoimmune disorder

Hashimoto’s thyroiditis is an autoimmune thyroiditis.  It is the most common form of primary hypothyroidism in the developed world.  Genetic predisposition to Hashimoto’s thyroiditis may also predispose someone to other autoimmune diseases (and vice versa).  


Nutrition-related Symptoms

(Differential diagnosis includes: anemia, other vitamin deficiency)

Changes in menstrual cycle
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

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

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