Introduction

General medicine, the cornerstone of healthcare, deals with a broad spectrum of illnesses and conditions affecting individuals across all age groups. A core skill for a general practitioner (GP) is the ability to accurately diagnose and manage complex cases often presenting with vague or overlapping symptoms. This case study explores the diagnostic and management challenges encountered in a patient presenting with persistent fatigue, a common yet often multifaceted complaint.

Patient Presentation

Mrs. Eleanor Vance, a 45-year-old female, presented to her GP complaining of persistent fatigue for the past six months. If you have almost any concerns relating to in which along with the way to use internal medicine x ray, you'll be able to e-mail us with our web page. She described her fatigue as overwhelming, affecting her ability to perform daily activities, including her job as a librarian and her hobbies of gardening and reading. She reported feeling constantly drained, even after adequate sleep. She also mentioned experiencing mild muscle aches, difficulty concentrating, and occasional headaches.

History Taking

A detailed history was taken to explore potential contributing factors. Mrs. Vance denied any recent travel or exposure to infectious diseases. She reported no significant past medical history, surgical procedures, or allergies. Her family history was unremarkable for chronic illnesses. She denied smoking, drank alcohol occasionally (one glass of wine per week), and consumed caffeine in moderation (two cups of coffee per day).

Regarding her social history, Mrs. Vance lived with her husband and two teenage children. She reported feeling stressed at work due to recent organizational changes and increased workload. She admitted to feeling overwhelmed by the demands of her family and work life. She denied any symptoms of depression or anxiety, although she acknowledged feeling frustrated and discouraged by her persistent fatigue.

A review of systems revealed no weight loss, fever, night sweats, changes in bowel habits, or skin rashes. She denied any chest pain, shortness of breath, or palpitations. She reported regular menstrual cycles.

Physical Examination

A thorough physical examination was performed. Mrs. Vance appeared well-nourished and in no acute distress. Her vital signs were within normal limits: blood pressure 120/80 mmHg, heart rate 72 bpm, respiratory rate 16 bpm, and temperature 36.8°C.

The examination revealed no significant abnormalities. Her skin was clear, with no rashes or lesions. Her lymph nodes were non-palpable. Her heart and lungs were clear to auscultation. Her abdomen was soft and non-tender. Neurological examination revealed intact cranial nerves, normal reflexes, and no sensory or motor deficits. Musculoskeletal examination revealed mild tenderness to palpation in the trapezius muscles, but no joint swelling or limitation of movement.

Differential Diagnosis

Based on the patient's history and physical examination, a broad differential diagnosis was considered, including:

Iron Deficiency Anemia: Common cause of fatigue, particularly in women of reproductive age.
Hypothyroidism: Can cause fatigue, weight gain, constipation, and cognitive impairment.
Vitamin D Deficiency: Widespread and can contribute to fatigue, muscle aches, and bone pain.
Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME): Characterized by persistent fatigue not relieved by rest, post-exertional malaise, and cognitive dysfunction.
Depression: Fatigue is a common symptom of depression, often accompanied by sadness, loss of interest, and sleep disturbances.
Anxiety Disorders: Can manifest as fatigue, irritability, and difficulty concentrating.
Sleep Apnea: Disrupted sleep can lead to daytime fatigue and cognitive impairment.
Underlying Medical Conditions: Such as diabetes, heart disease, or autoimmune disorders.
Fibromyalgia: Characterized by widespread musculoskeletal pain accompanied by fatigue, sleep disturbances, and cognitive dysfunction.
Medication Side Effects: Certain medications can cause fatigue as a side effect.
Lifestyle Factors: Including stress, poor diet, and lack of exercise.

Investigations

To narrow down the differential diagnosis, the following investigations were ordered:

Complete Blood Count (CBC): To assess for anemia and infection.
Thyroid Stimulating Hormone (TSH): To evaluate thyroid function.
Vitamin D Level: To assess for vitamin D deficiency.
Iron Studies (Serum Iron, Ferritin, Transferrin Saturation): To evaluate for iron deficiency.
Comprehensive Metabolic Panel (CMP): To assess liver and kidney function, electrolytes, and glucose levels.
Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): To screen for inflammation.
Urinalysis: To screen for urinary tract infection and kidney disease.

Results and Diagnosis

The laboratory results revealed a low ferritin level (15 ng/mL; normal range 20-120 ng/mL), indicating iron deficiency. All other laboratory tests were within normal limits.

Based on the patient's history, physical examination, and laboratory results, a diagnosis of iron deficiency anemia was made. While the patient did not exhibit classic signs of anemia like pallor, the insidious onset of fatigue and the low ferritin level strongly supported the diagnosis.

Management

Mrs. Vance was started on oral iron supplementation (ferrous sulfate 325 mg three times daily). She was advised to take the iron supplements on an empty stomach with orange juice to enhance absorption. She was also counseled on dietary sources of iron, such as red meat, leafy green vegetables, and fortified cereals.

In addition to iron supplementation, Mrs. Vance was encouraged to address her stress levels through lifestyle modifications. She was advised to engage in regular exercise, practice relaxation techniques such as yoga or meditation, and prioritize sleep hygiene. She was also referred to a therapist for cognitive behavioral therapy (CBT) to help manage her stress and improve her coping mechanisms.

Follow-Up

Mrs. Vance was scheduled for a follow-up appointment in six weeks to reassess her symptoms and monitor her iron levels. At the follow-up appointment, she reported a significant improvement in her fatigue levels. She was able to perform her daily activities with greater ease and had more energy for her hobbies. Her repeat ferritin level had increased to 40 ng/mL.

The iron supplementation was continued, and Mrs. Vance was advised to maintain her healthy lifestyle habits. She continued to attend therapy sessions and reported feeling more equipped to manage her stress.

Discussion

This case highlights the importance of a thorough history and physical examination in the evaluation of patients presenting with fatigue. While fatigue is a common symptom with a broad differential diagnosis, a systematic approach can help identify the underlying cause. In this case, iron deficiency anemia was identified as the primary contributor to Mrs. Vance's fatigue.

It is also important to consider the role of psychosocial factors in the management of fatigue. Stress, anxiety, and depression can exacerbate fatigue and hinder recovery. Addressing these factors through lifestyle modifications and therapy can significantly improve patient outcomes.

General practitioners play a crucial role in the diagnosis and management of fatigue. By taking a holistic approach and considering both medical and psychosocial factors, GPs can provide effective and comprehensive care to patients presenting with this common and often debilitating symptom. This case also demonstrates the importance of follow-up and monitoring to ensure that treatment is effective and that patients are making progress towards recovery.