Level 2: Fatigue – Contrasting Case #2: 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 is of normal body habitus and is in no acute distress. She reports that she has felt more tired than normal for maybe the last few months, but doesn’t know exactly when it started. She hasn’t been sleeping well, only averaging 5 hours of sleep a night compared to 8 hours previously. She also reports feeling tremulous and like her heart races even when she’s at rest. Her mom reports that during this same time frame she has noticed a decreased attention span and her grades have started to decline. She also seems more moody. Patient does not have a history of ADHD and has never had trouble with concentration before. Her mom is concerned about her clothes fitting more loosely than normal even though she’s eating everything in the house.

Patient has no known medical conditions. She does not take any medications, vitamins, or supplements.
There is a strong family history of autoimmune diseases. Mother (37): Hyperthyroidism and Celiac
Disease. MGM (59): Rheumatoid arthritis, HTN, hyperlipidemia.

Physical Exam –

Vitals: Height 5’6 (80th %ile — up from 50th %ile 2 years ago), Weight 110 lbs (45th %ile), BMI 17.8 (22nd %ile), HR 90, BP 128/58, RR 16, temp 98.6 F
General: Weight loss of 8 pounds in two months despite increased appetite and food intake. No fever or chills.
HEENT: No syncope, visual changes, hearing changes, sore throat, rhinorrhea, dysphagia, or enlarged lymph nodes. Normocephalic, PERRLA, lid lag is present when testing visual fields, tympanic membranes normal with cone of light bilaterally, nasal mucosa pink/moist without exudate, oropharynx pink/moist without exudate or erythema.
Cardiovascular: Heart races at rest intermittently. No chest pain. Regular rate and rhythm, S1 and S2 are of normal intensity, no S3 or S4, a midsystolic click followed by a brief crescendo-decrescendo murmur is heard best over the apex, no peripheral edema, pulses are 2+/4 bilaterally throughout, no bruits.
Respiratory: No dyspnea or cough.
GI: No abdominal pain, nausea, vomiting, diarrhea, or constipation.
Endocrine: No polydipsia or polyuria. Feels warm often and sweats a lot more than other people her age. Increased hair loss and dry skin.
Neck: Lymph nodes are small, nontender and freely moveable; thyroid is slightly enlarged, smooth, fleshy in consistency, without palpable nodules, and nontender; no JVD
Respiratory: Clear to auscultation in all lung fields bilaterally.
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 warm and smooth, no rashes or lesions.