A 49 year old female patient with Chronic Fatigue and Hypothyroidism

6th September 2023

CASE STUDY 21

Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients de-indentified health data after taking his/her consent. This also reflects my patient centered online learning portfolio. Below mentioned links are solely for a better understanding purpose and an insightful intake!

This is the case of a 49 year old female, resident of West Bengal who was interviewed through a telephone conversation. A thorough history was taken which is as follows.

CASE SHEET:

CHIEF COMPLAINTS:

c/o

- Fatigue and muscle weakness since 3.5 years.

- Disturbed sleep during the night since 1-2 years.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 years ago when she started complaining of fatigue and tiredness in carrying out daily household activities which she earlier was able to do without any hassle.

She also complained of joint pains and weakness in her legs since 2-3 years now which is aggravated in colder climate. The pains are dull and mild for which she was advised medication for a week time and then stopped. The pain does not cause a major hinderance in her daily activities.

Since 4 years she also has complaints of feeling of giddiness and weakness whenever she carries out her daily chores in her house which previously she did not use to experience.

Since 4 years she also has been experiencing alot of hair fall which has now gradually reduced after medication.

Since 2 years she has been complaining of palpitations whenever she is carrying out her household work or any work for that matter which relieves after she takes rest. She does not consume any medication for the same.

2 years back she experienced an episode of acid reflux for around 4-5 days. It was accompanied by nausea and vomiting which was non bilious, non blood stained and watery in appearance which was relieved by medication.

She has a dry skin including facial skin and rough and dry hair since 2-3 years.

She has experienced weight loss in the past 3 years from 58 kgs to 48 kgs.

She has no complaints of loss of memory, inability to concentrate, or any impaired hearing. She also does not complaining of numbness or tingling sensation.

She has ongoing reasons for psychological stress due to her older daughter and various other household affairs.

She is having difficulty in falling asleep and has a disturbed sleep especially during the night since a year or 2.

Her daily routine before the above complaints :

She used to wake up at around 5- 530 am.

She makes breakfast around 9 am. She eats the same.

She washes the utensils and clothes everyday for her and her family. She also cleand and mops the house.

Later she prepares lunch in the afternoon time for herself and her family.

she consumes tea/coffee in the evening whenever she wishes to.

Later at night she eats dinner which she prepares herself.

She goes to sleep around 10-11pm.

Her daily routine after the above complaints :

She wakes up around an hour late at 6 - 6:30am.

She doesn't complain of any tiredness when she gets up.

She has appointed a house-maid to cook daily food 3 times a day as she gets tired after cooking.

She also has appointed another maid to do household chores for the same above reason.

She eats food 3 times a day and goes to sleep around 10:30pm during the night.

Disturbed sleep and difficulty to fall asleep still persists.

Daily food intake:

For Breakfast she has puffed rice(muri) with milk & 1 banana.

For Lunch she has rice, dal, sabji and fish.

For Dinner she again has rice, dal, sabji and fish

On weekends she consumes items like Paneer and dal.

She also consumes 4 pieces dates everyday in the morning.

There is :

-h/o constipation since 3 years on usage of iron and calcium supplement capsules. She later switched to syrup for the same to avoid constipation.

-h/o weight loss of 10kgs since 2020.

-no h/o SOB.

-no h/o fever with rash.

-no h/o diarrhea.

-no h/o burning micturition.

-no h/o cough with sputum.

-no change in voice.

-no facial puffiness.

PAST HISTORY:

MEDICAL:

No K/C/O HTN, DM, Epilepsy, TB, CAD, CKD.

SURGICAL:

Around 16 years ago for the delivery of her 2nd child, she underwent a LowerSection Caeserian Section.

10 years ago on a general examination of USG as advised by her doctor it was found out that she has a uterine cyst. This was removed by surgical intervention.

Around last year in October 2022 she again underwent an USG examination and was found to have an ovarian cyst which was removed by surgical intervention.

No h/o Blood Transfusions.

MENSTRUAL HISTORY:

Attained menopause around 4 years ago.

Previously she used have menorrhagia, not associated with pain but with associated 1×2cm clots on the 1st and 2nd day. She used to bleed for 5 days and used around 3-4 pads everyday.

PERSONAL HISTORY:

She is married.

Consumes a mixed diet.

Normal appetite.

Disturbed sleep.

Regular Bowel and Bladder movements interfered by intermittent constipation.

Has no known allergies.

Has no known addictions.

FAMILY HISTORY:

h/o Father having brain cancer.

Has N/K/C/O Diabetes Mellitus, No HTN, No Strokes. No CAD, TB, Asthma or Epilepsy.

GENERAL EXAMINATION: