Question

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 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 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 3^rd, 4^th and 5^th digits of right foot.

The results of Ms. Jones’ tests are listed below.

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 ratio	15.6	0-29.9 (mcg albumin/mg cr)
Hemoglobin A1c	8.9%	4.8-6.0%
Electrocardiogram	normal

Treatment Plan

Please outline a plan for treatment.

In addition, in your treatment plan, you should address the following questions:

1. What education and counseling would you like to provide for the patient? What parts of this education would you provide today and what would you put off until another visit?
2. What specialist consultants and other professionals would you like to involve in the care of this patient?
3. When would you like to see this patient in follow-up? How often would you like to see her?
4. What ongoing monitoring should this patient have, and how often should it occur?

Answer 1

Burning with urination, vaginal discharge, increased frequency of urination, increased thirst, fatigue, and HbA1C of 8.9% show that the patient probably has diabetes with urinary tract infection (UTI). Family history of type 2 diabetes mellitus in mother and sister also points to the probability of type 2 diabetes mellitus. Quite often UTI is seen associated with diabetes mellitus, which also points to the possibility of type 2 diabetes mellitus. Steps in the plan of treatment would be:

1. Further tests to confirm diabetes.

2. Test for UTI.

3. Patient should drink plenty of fluids.

4. She should avoid high-carbohydrate junk foods and sugary foods.

5. She should increase the amount of fiber, protein, and vitamins in food by including more vegetables, whole grain food, etc.

6. She should stick to 1200 calories per day diet for weight loss.

7. She can continue with low-fat food choices.

8. She can change to a daily 20 minutes walk exercise program.

All the above patient education will be provided today. More information about exercise and healthy food choices will be given later. Further diabetic care and hygiene issues will be addressed next visit. The patient will be referred to an OB/GYN provider, dietitian, etc. The patient can follow up next week after obtaining the test results. She will be seen on a monthly basis after that. The patient should have dietary monitoring with the calorie count. She should also monitor her daily random blood sugar levels. She should also check her weight daily to know the effect of the diet and exercise program.