A 31-year-old woman is assessed for difficulty sleeping and feeling exhausted nearly every day for the past 6 months. When the patient pushes herself to perform basic household tasks, she has no energy for the next 1 or 2 days and says, "My muscles ache for hours afterward." She gets 6-7 broken hours of sleep a night and does not feel rested on awakening. The patient also has intermittent headaches and difficulty concentrating. Other than an episode of influenza 8 months ago, she has been in good health.
The patient describes feeling "down in the dumps" as she cannot go to the gym or socialize with friends as she once did. She works as a counselor but has recently missed at least a day of work a week due to worsening exhaustion and body aches. She enjoys her job and is anxious that the frequent absences will result in her termination; she asks the physician for a doctor's note. The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs and physical examination are unremarkable.
Laboratory results are as follows:
Which of the following is the most likely diagnosis in this patient?

Question

A 31-year-old woman is assessed for difficulty sleeping and feeling exhausted nearly every day for the past 6 months.  When the patient pushes herself to perform basic household tasks, she has no energy for the next 1 or 2 days and says, "My muscles ache for hours afterward."  She gets 6-7 broken hours of sleep a night and does not feel rested on awakening.  The patient also has intermittent headaches and difficulty concentrating.  Other than an episode of influenza 8 months ago, she has been in good health.
The patient describes feeling "down in the dumps" as she cannot go to the gym or socialize with friends as she once did.  She works as a counselor but has recently missed at least a day of work a week due to worsening exhaustion and body aches.  She enjoys her job and is anxious that the frequent absences will result in her termination; she asks the physician for a doctor's note.  The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs and physical examination are unremarkable.
Laboratory results are as follows:
 Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's presentation suggests chronic fatigue syndrome (CFS), also known as systemic exertion intolerance disease (SEID). CFS affects primarily young to middle-aged adults and is twice as common in women. It may be misdiagnosed as malingering due to lack of objective findings. Diagnosis involves excluding other causes of fatigue with a thorough history, physical examination, and laboratory evaluation (eg, complete blood count, metabolic panel, TSH level, erythrocyte sedimentation rate). Potential causes that must be excluded include psychiatric disorders (eg, depression, anxiety), which may also be comorbidities, and medical conditions. Clinical clues suggesting CFS include: Sudden onset of fatigue, often after an upper respiratory infectionResolution of infection with residual intense fatigue and sleep or cognitive disturbancesSymptoms exacerbated by physical activityPatients usually healthy and highly functioning prior to onset of fatiguePhysical examination typically normal Sudden onset of fatigue, often after an upper respiratory infection Resolution of infection with residual intense fatigue and sleep or cognitive disturbances Symptoms exacerbated by physical activity Patients usually healthy and highly functioning prior to onset of fatigue Physical examination typically normal First-line treatment includes cognitive-behavioral therapy and graded exercise therapy. (Choice B) Fibromyalgia is characterized by diffuse musculoskeletal pain, with tenderness on examination. This patient has fatigue rather than pain, and her physical examination is normal, making CFS the more accurate diagnosis. (Choice C) There is no evidence that this patient is feigning her symptoms for an external goal, which would be the case in malingering. (Choice D) Persistent depressive disorder (dysthymia) is characterized by a depressed mood for most of the day for at least 2 years. This patient's depression stems from her fatigue and has been present for only 6 months. In addition, the fact that she continues to enjoy her work, had symptom onset following infection, and has debilitating muscle aches after exertion make CFS more likely than dysthymia. (Choice E) Somatic symptom disorder typically involves multiple organ systems and is more likely when there is no medical explanation for symptoms; it has an early onset and a chronic course. This patient's 6-month history of fatigue and exercise intolerance is consistent with CFS. Educational objective: Chronic fatigue syndrome is characterized by a relatively sudden onset of intense fatigue that is worse on exertion, is not relieved by rest, and represents a marked deterioration from a previous level of functioning. Sleep and cognition are commonly affected. Treatment includes cognitive-behavioral therapy and graded exercise therapy. __________ References: Chronic fatigue syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23312650) Chronic fatigue syndrome: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/23062157)

A 31-Year-Old Woman Is Assessed for Difficulty Sleeping and Feeling