Patient Description. Brad is a
43-year-old motivational speaker and married father of four young children who
was entirely well until one year ago.
Complaint. Brad now presents with chief complaints of persistent
fatigue, recurrent flu-like feelings and difficulty concentrating. He relates
that whenever he “pushes” himself, he experiences terrible exhaustion, muscle
pain, aching in various joints, soreness in the neck, burning eyes and, on two
occasions only, indigestion and diarrhea. These symptoms may last one or two
days, then subside somewhat. He is clumsy and bumps into things around the
house. He notes new difficulties with memory, mental confusion, easy
distractibility, word searching, difficulty making even simple decisions,
trouble with even simple math and occasional disorientation or confusion, even
in familiar surroundings. His complaints include generalized weakness,
“restless” legs and jerking at night, night sweats, tender glands in the neck
and feverish feeling but subnormal temperatures. Sleep is shallow and disrupted,
and he wakes up feeling worse than when he went to
History of Present Illness. He awoke
one morning with fever and a “terrible flu-like feeling.” He consulted his
primary physician when he did not improve over several days. Initial evaluation
revealed mildly elevated liver function and a slightly positive ANA, but
otherwise the examination and laboratory did not reveal the cause of his
illness. He has been essentially housebound for the past six months, but is able
to handle most of his personal activities of daily living. However, he has had
to hire a yardman and housekeeper to help out with chores. He has been
physically active for up to four hours at a time “safely,” but some days he has
been unable to do anything.
History. Brad’s past medical history is remarkable only for
herniorrhaphy, repair of a severed nerve in the finger and cystoscopy following
a GU infection. The family history is remarkable for depression in the patient’s
mother and sister. There is no history of alopecia, sun sensitivity, recurrent
rash, pleurisy or other serositis, recurrent mouth ulcers, Raynaud’s phenomenon,
hematuria or kidney disease. There has been no swelling, heat or redness at the
joints. There has been no abdominal pain, recurrent diarrhea or hematochezia of
Brad reports a travel history.
He recalls a back-woods camping trip in Wisconsin with the family sometime prior
to the onset of his symptoms. Also, in his work as a motivational speaker, Brad
traveled frequently. He reports a single episode of extra-marital sex while away
on business a few years ago. He reports he did not use a condom at the
Question: What should be done next?
(Select all that apply.)
Perform physical examination.
B. Order complete
blood count (CBC), chemistry panel, erythrocyte sedimentation rate (ESR),
thyroid function tests (TFTs) and urinalysis with microscopic evaluation (UA
C. Order rheumatoid factor (RF),
anti-nuclear antibody profile for double-stranded DNA
D. Obtain blood cultures and viral
E. Request gastroscopy and colonoscopy.
F. Order HIV tests.
Order Lyme Disease tests.
H. Refer the patient for a
thorough psychiatric evaluation.
Answer: A, B, C, F and
Perform a thorough physical
examination and order and then interpret limited exclusionary laboratory studies
to confirm or rule out the differential diagnoses. Key tests include CBC (to
rule out elevated white count) and a chemistry panel. If liver function
tests are elevated, a hepatitis profile should be ordered as well. Rheumatoid
factor and DsDNA (anti-DNA antibodies) tests are ordered to rule out or in
rheumatoid arthritis and systemic lupus erythematosus, respectively. Kidney and
thyroid diseases, which may cause fatigue, are ruled in or out with other
There is insufficient reason to
order blood cultures as Brad has no fever or hematuria. Although many cases of
chronic fatigue syndrome, including Brad’s case, begin with a flu-like illness,
there has been no scientific evidence that a specific virus triggers or
perpetuates this disorder. Hence, viral titers are not indicated.
The absence of persistent
gastrointestinal symptoms makes endoscopic evaluation of the GI tract
unnecessary at this time.
Brad’s symptoms, his history of
unsafe sex in the past and his travel history should lead the clinician to order
testing to rule out or in HIV and Lyme disease.
Finally, although you have
identified no physical cause for Brad’s complaints yet, there has been no
compelling reason to assume that they are psychiatric in origin. The primary
care clinician, however, should evaluate Brad with the Beck Depression
Inventory™ or other screening tool to assess whether Brad is depressed. A
psychiatric or psychological referral is not indicated at this time.
Patient Description. Judy is a 21-year-old single woman
from the Midwest who relates her onset of symptoms to a flu-like illness when
she was only 14 years old.
“Whenever I try to do very much, I crash.”
History of Present
Illness. Judy’s entire family was affected with fever, sore
throat, fatigue and upper respiratory congestion at the same time. Although her
father remained ill for four months, every one else recovered while Judy
developed overwhelming fatigue, migratory joint pain, intermittent abdominal
pain, photophobia, new pressure-like headaches, dizzy spells and difficulty
All of her symptoms were worse
with even minimal exertion. Judy had difficulty keeping up with school —
especially math — and she described a “brain fog” or lack of mental acuity. Judy
felt dizzy on rising quickly, and she developed weakness and faintness when
standing for short periods in church or even in the shower. She was unable to
keep up at school, and dropped out to take homebound classes. She has been
frustrated and disappointed by her inability to attend school and socialize with
her friends, and gets weepy at times but denies being depressed.
#1: A reasonable differential diagnosis includes
which of the following? (Select all that apply.)
Chronic fatigue syndrome.
B. Collagen vascular
disorder, such as sys-temic lupus.
disorder, e.g., juvenile rheumatoid arthritis.
E. School phobia or
F. Chronic hepatitis.
#1: All of the above
The chief complaint of
exertional fatigue, recurrent flu-like feelings, and neurocognitive problems is
a classical triad of symptoms for chronic fatigue syndrome.
Collagen vascular disease and
the arthridites are possible, but not well supported by history.
An infectious illness such as
Lyme disease or chronic active hepatitis could persist, but other diseases are
unlikely to persist for several years.
Teens with school phobia may
present with a number of symptoms in an effort to avoid school. Judy was doing
quite well at school, however, and she had none of the other hallmarks of school
phobia such as academic problems, difficulty with personal relationships, or
difficulty separating from her parents.
There was no evidence of
malingering or Munchausen by proxy.
#2: Is CFS infectious?
Although outbreaks or “epidemics” of
chronic fatigue syndrome have been reported, no infectious agent has ever been
identified and epidemiological studies are not consistent with an infectious
agent; there is little evidence for person-to-person spread, a vector or a fixed
incubation period. Nevertheless, the onset of chronic fatigue syndrome occurs
after an acute viral-like illness in the majority of cases, and most cases are
sporadic rather than epidemic. Toxic agents, radiation exposure and the like can
also explain these “epidemics,” but no such non-infectious causes have been
associated yet with chronic fatigue syndrome.
#3: Should a psychological evaluation be
It may be difficult to diagnose
psychological disorders and stressors, especially in children and young adults.
If any such diagnoses are suspected, referrals to the appropriate professionals
should be made. Screening instruments such as the HDAS (Hospital Depression
Assessment Scale) can be used to help determine whether the patient needs
referral. Repeat screening with this instrument is also useful in screening for
new onset of depression and anxiety in chronic illnesses such as