57 Year Old Woman with Fatigue

Chief Complaint: Fatigue

History of Present Illness:

Ms. Jones is a 57 year old woman who presents to her primary care physician with a three month
history of fatigue. She reports that she doesn’t seem to have as much energy as she used to for
daily activities. She has also noted increased frequency of urination, often having to get up two
to three times a night to go to the bathroom. She has increased her intake of liquids because she
feels thirsty all of the time. She is also experiencing headaches. She describes them as a dull,
generalized pain, without accompanying photophobia, phonophobia, nausea, vomiting, visual
changes or focal neurologic symptoms. Occasional headaches have been occurring over the last
three months, but in the last week they have increased in frequency and severity and are now
occurring daily. In the last week she has also noted that urination has become even more
frequent, and she experiences a burning pain when she urinates.

Past Medical History:

1. Allergic rhinitis
2. Gastroesophageal reflux disease

Allergies: NKDA

Medications:
1. loratadine 10mg po daily as needed for nasal congestion
2. omeprazole 20mg po daily as needed for heartburn
3. acetaminophen 1000mg as needed for headache

Past Surgical History: no prior surgeries

Family History:
Mother with hypertension and type 2 diabetes mellitus, died at age 71 of CVA. Father, age 79,
with hypertension and coronary artery disease. Sister, age 55, with hypertension and type 2
diabetes mellitus. Daughters healthy at age 29 and 33. Maternal aunt died of breast cancer at
age 62.

Social History:
Ms. Jones works as a bank teller. She is married and has two adult daughters. She has smoked
half a pack of cigarettes daily for the last 30 years. She drinks a beer or glass of wine
approximately once a week and denies other drug use. She is sexually active in mutually
monogamous relationship with her husband. Ms. Jones has recently begun trying to lose weight.
She walks for exercise about 20 minutes every other week. She is attempting to eat a healthier
diet by purchasing low fat versions of the products she usually buys at the grocery store.

Health Maintenance:
1. Last pap smear 2 years ago, negative. No history of abnormal pap smears.
2. Last mammogram one year ago, normal.
3. Last colorectal cancer screen: colonoscopy 7 years ago, normal other than diverticulosis.
4. Influenza immunization in November of last year.
5. Does not recall if her cholesterol or blood sugar have ever been tested.

Review of Systems:
- General: Increasing fatigue over the last 3 months, per HPI. Ten lb. weight gain over the last
18 months. No recent fever or chills. Intermittent headache.
- Eyes: Has noted blurred vision in the last 3 weeks. No eye pain, redness.
- Ear/Nose/Throat: No hearing loss, tinnitus, vertigo, earaches, nasal congestion, discharge,
epistaxis, dental problems, sore throat.
- Neck: no lumps, pain, stiffness.
- Skin: no rashes.
- Breasts: No lumps, pain, discharge.
- Respiratory: No shortness of breath, cough, hemoptysis, wheezing.
- Cardiac: No chest pain, dyspnea on exertion, palpitations, orthopnea, PND, peripheral
edema.
- Gastrointestinal: heartburn 1-2 times per month. No nausea, vomiting, abdominal pain,
diarrhea, constipation, blood in stools or melena.
- Genitourinary: Three day history of white vaginal discharge and itching in the vaginal area.
Nocturia 2-3x per night. Dysuria, per HPI. No hematuria, urgency. LMP 8 years ago.
- Musculoskeletal: No pain, stiffness, swelling in joints or muscles.
- Neurologic: No focal weakness or numbness, paresthesias.
- Hematologic: No easy bruising or bleeding.
- Endocrine: Polyuria, polydipsia per HPI. No heat or cold intolerance,.
- Psychiatric: No depression, anxiety.

Physical Exam:
- Vital signs: P 84, RR 16, BP 147/92 T 37.2, weight 192 lbs, height 5’5”.
- General: Alert, well-appearing, in no acute distress.
- HEENT: PERRLA, conjunctivae and sclera clear, mucous membranes somewhat dry.
- Neck: supple, without masses, lymphadenopathy, or thyromegaly.
- Pulmonary: Lungs clear to auscultation bilaterally with good air movement and symmetrical
expansion.
- Cardiovascular: Normal S1, S2 without murmurs, rubs or gallops. Radial and dorsalis pedis
pulses symmetric, 2+ bilaterally, no peripheral edema.
- Abdomen: Normoactive bowel sounds, nontender, nondistended, no masses or
organomegaly.
- GU: Generalized erythema of vulvar tissues. Thick, white discharge in vaginal vault. No
cervical motion tenderness, fundal or adnexal tenderness.
- Skin: No rashes or other lesions other than white, macerated lesions in the webspace between
3rd, 4th and 5th digits of the right foot.
Test Patient’s Results Normal Values
Sodium 140 mmol/L 135-145 mmol/L
Potassium 3.8 mmol/L 3.5-5.0 mmol/L
Calcium 9.0 mg/dL 8.5-10.2 mg/dL
Creatinine 0.9 mg/dL 0.6-1.0 mg/dL
eGFR >60mL/min/1.73M2 >60mL/min/1.73M2
Hemoglobin 13.2 g/dL 12.0-16.0 g/dL
total cholesterol 257 mg/dL <200 mg/dL
LDL 178 mg/dL <100 mg/dL
HDL 30 mg/dL >40 mg/dL
triglycerides 245 mg/dL <150 mg/dL
Microalbumin/creatinine 15.6 0-29.9 (mcg albumin/mg cr)
ratio
Hemoglobin A1c 8.9% 4.8-6.0%
Electrocardiogram normal

Her finger stick capillary blood glucose level was 235 mg/dl. A vaginal wet mount showed
yeast, and she was treated with fluconazole 150mg po for vaginal candidiasis and clotrimazole
1% cream twice a day for tinea pedis. A urinalysis was positive for nitrite and 15-20 WBCs/hpf.
She was treated for a urinary tract infection with trimethoprim/sulfamethoxazole 160/800mg
twice a day for seven days. Her blood pressure is 152/95.

Ms. Jones is started on metformin 1000mg twice a day, glipizide 10mg daily, lisinopril 40mg
daily, chlorthalidone 50mg daily, and lovastatin 80mg daily. On this regimen, her blood pressure
is 136/84, her hemoglobin a1c is 7.2%, and her LDL cholesterol is 95 mg/dL. She successfully
quits smoking using bupropion, nicotine replacement therapy and counseling services through
the NC Quitline.