Level 3: 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 16 year old female who presents to the clinic for evaluation of fatigue for two weeks. She reports: “I just feel lousy and tired all the time.” She is in no acute distress, but appears sick.

HPI: Patient is previously healthy. She states that approximately two weeks ago she began to experience insidious onset lethargy. Ms. Branch reports that “all of a sudden, I just didn’t have my usual zip”. She denies any precipitating factors or experiencing this before. Patient reports that despite getting enough sleep each night, she constantly feels exhausted and no longer has the energy to do the things she used to do. During this time she also states that she has had occasional low-grade fevers. Patient reluctantly admits that her boyfriend has had similar symptoms.

PMH: Non-contributory

SH: Patient is a junior in high school. She denies any current or prior use of tobacco, alcohol, or illicit drugs.

FMH: Father- Alive and healthy at age 44, Mother- Alive and healthy at age 46, Brother-Alive and healthy at age 18, Sister –Alive and healthy at age 9

HEENT- No visual or hearing changes. Reports a mild sore throat for the past two weeks.
Abdomen- Patient states that she hasn’t felt like eating for the past week. No recent diarrhea, constipation, nausea, or vomiting. No recent abdominal pain.
Musculoskeletal- No myalgias or arthralgias.

VS- Height 5’8’’, Weight 160lbs, BMI 24.3 HR 60, BP 124/88, RR 12, Temperature 99.7
General Appearance- Patient is cooperative and in no acute distress.
HEENT- Normocephalic, atraumatic, PERRLA, tympanic membrane unremarkable bilaterally. Nasopharynx examination reveals pink, moist turbinates. Oropharynx shows mildly erythematous uvula with otherwise unremarkable mucosa.
Neck- Thyroid non-palpable. No JVD present. Anterior Cervical lymphadenopathy present bilaterally. No occiput, auricular, submandibular, submental, or supraclavicular lymphadenopathy present.
Abdomen- Bowel sounds active in all 4 quadrants. No tenderness to light or deep palpation. Liver not palpable and murphy sign negative. Spleen is palpable and mildly tender.

Heterophile Antibody Test- Negative
Serology- Positive for Cytomegalovirus