Level 1: Fatigue – Contrasting Case #3: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 29 year old female, presenting to the clinic for recent fatigue. She is in no acute distress. Her chief complaint is: “I just don’t feel like doing anything anymore.”

HPI: Mrs. Mason, a previously healthy 29 year old female, presents to the clinic with complaints of fatigue for the past 2 weeks. She states that for the past two weeks, she has had been experiencing rhinorrhea and sneezing. Mrs. Mason states that these are her usual seasonal allergy symptoms, but that they seem “worse than usual for whatever reason”. Mrs. Mason states that during this time she has been taking 1-2 Benadryl in the morning and at night in addition to her usual dosage of Claritin. Patient states that the addition of the Benadryl seemed to make the rhinorrhea and sneezing “a little bit better,” but she states that since then she always feels “very sleepy”.

PMH: Reports seasonal allergies, treated by 10 mg Claritin PRN daily

FMH/SH: Noncontributory

PE: All within normal limits