Case Overview: Mrs. B is a patient to be seen by you as an outpatient: Mrs. B is a 34-year-old white female who presents with the chief complaint of fatigue, headaches and backache. Her symptoms have been present for approximately 4 to 5 weeks, and they are worsening in severity, frequency, and duration. Her headaches are generalized and non-pulsating. She says it feels “like my skin is too tight for my head”. She experiences an average of 3-4 headaches per week. They are not associated with an aura, nausea, vomiting, photophobia, visual abnormalities, focal neurologic defects, neck pain, irregular eating habits, or skipping meals. There are no precipitating or aggravating factors of which Mrs. B is aware. Her aches are alleviated in less than one hour by taking two regular strength Tylenol tablets. She is not experiencing any daytime sleepiness or insomnia, yet she awakens just as tired as she was before retiring. In an attempt to alleviate this problem, she adjusted her bedtime several times to get more sleep; unfortunately, this was not effective. She is now sleeping 11 to 12 hours per night. She misses approximately one day of work per week because she’s “just too tired to get up and go”. She works as a receptionist and has been reprimanded by her supervisor several times in the past few months not only for her frequent absenteeism but also for taking too long to complete customer transactions. She commits frequent errors in which she describes being too tired to think straight. She also complains of easy distractibility, poor memory, and being irritable towards coworkers and customers. Her headaches and fatigue do not appear to be any different weekends as they are on weekdays. She denies excessive stress, anxiety, depression, or sadness. However, she does feel down because she fears getting fired from her job. She suffers from anhedonia and declining social invitations because she’s just too tired. She is not experiencing any fever; changes in the textures of her hair, oiliness of her skin, or consistency and strength of her fingernails; bowel changes, chest pain/pressure; palpitations; shortness of breath; or pedal edema. She was seen in the ER approximately 4 weeks ago, at which time they performed a CT of the brain. The ER advised her that the diagnostic studies were normal and her symptoms were caused by stress. They prescribed lorazepam 0.5 mg at bedtime. She did not start this medication because she emphatically denies this as a possible diagnosis because she has not experienced any increase in her stress level. Current medications include Lopid and Tylenol as needed; no over-the-counter medications, vitamins, supplements or herbal preparations. Social history: Mrs. B is a life-long nonsmoker. She drinks one or two alcoholic beverages per week and denies the use of any illicit drugs. She has no known problems with her marriage. She is sexually active and has a copper/containing IUD for birth control. It was inserted five months ago. Her last menstrual period was three weeks ago and was normal. Her IUD string is palpable after her last menses. Assignment Instructions: (use a minimum of 4 peer-reviewed sources to support your responses): 1. Based on the information provided in the case overview, please rank the following history questions (1-most important to 5-least important) and discuss why or why not they are essential to ask Mrs. B and why? (List sources) – How does she define fatigue and what is the pattern over a typical day? – Has she been experiencing a sore throat, cervical lymphadenopathy, axillary lymphadenopathy, arthralgias, myalgia’s, or severe post-exertional fatigue? – Has she experienced a recent, unintentional weight change? – Has she experienced any episodes of increased activity associated with a decreased need for sleep, grandiosity, enhanced self-esteem, euphoria, behavior unusual or outrageous for her, beginning many projects but not finishing any, racing thoughts? – Has she considered suicide?
