Level 2: Fatigue – Contrasting Case #1: 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 pleasant 15 year old girl who presents to her primary care physician accompanied by her mother. She has a thin body habitus and is in no acute distress. She reports she has felt tired for about one month. She has also felt weak and finds it difficult to keep up with her cross country teammates on runs like she used to. She averages 9 hours of sleep a night, which is increased from her normal 7 hours, yet she does not feel rested. Her mother reports she does not snore and is a restful sleeper. The patient also reports she cannot concentrate as well in school and is afraid her grades might start to decline. She does not report loss of interest in activities, feelings of guilt, change in appetite, psychomotor retardation/agitation, suicidal thoughts, or feeling depressed. She is not being bullied at school and says she is a good student who gets along with all of her classmates.

Patient has no known medical conditions. She does not take any medications, vitamins, or supplements.
She went through menarche at age 13. Her last menstrual period was 2 weeks ago.
Her menstrual cycle occurs every 28 days and lasts 7-8 days. She does not report clotting, but reports she uses about 10 tampons a day. She is not on birth control and denies being sexually active.
She has been a vegetarian for five months since she watched a movie in health class about meat products.

Physical Exam –
Vitals: Height 5’3 (50th %ile), weight 100 lbs (20th %ile), BMI 17.7 (21st %ile), HR 60, BP 110/62, RR 16,
temp 98.6 F
General: Well-developed, well-nourished adolescent female in no acute distress. Appears slightly pale.
HEENT: Normocephalic, PERRLA, tympanic membranes normal with cone of light bilaterally, nasal mucosa pink/moist without exudate, oropharynx pink/moist without exudate or erythema. Conjunctiva are pale and moist.
Neck: Lymph nodes are small, nontender and freely moveable. Cardiovascular-regular rate and rhythm, S1 and S2 are of normal intensity
Respiratory: Clear to auscultation in all lung fields bilaterally, no wheezing, or rales
Abdominal: Bowel sounds present in all four quadrants, nontender to light and deep palpation, liver
edge is smooth and normal span, spleen is not palpable
Neuro: Alert and oriented to person, place, and time; no neurological deficits; cranial nerves intact; patellar, Achilles, and biceps deep tendon reflexes 2/4 bilaterally
Skin: Good skin turgor, skin is pale and warm, no rashes or lesions.

CBC: Hb <11.0 g/dL Serum Ferritin <12 ng/mL