Case
Jill McHale is a 43 year old woman who reports that she has been feeling very tired over the last few months. She lives with her husband Brian, her 15 year old daughter Theresa, and her 10 year old son Patrick. She does not work outside her home.
Over the years, she has gone to the emergency room on three separate occasions for fractures of her left clavicle, superficial trauma to her face, and a minor concussion.
She is withdrawn but pleasant in your office. She is 66 inches tall and weighs 120 pounds. (She weighed 135 pounds in your office six months ago). Her vital signs are normal, as is the rest of her physical exam. Health Maintenance including cervical cancer screening is all up to date.
Questions to Consider
What additional history is needed?
What is the differential diagnosis?
What tests would you order (if any)?
How would you manage this case?
Learning Objectives
- Develop a differential diagnosis of fatigue and depression.
2. Screen for common causes of fatigue.
3. List initial treatments for depression.
MAJOR DEPRESSIVE DISORDER DIAGNOSTIC CRITERIA – “SIGE CAPS”
To diagnose a major depressive episode, at least 5 of the following 9 symptoms must have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms must be either (a) depressed mood or (b) loss of interest or pleasure.
- Sleep – increased or decreased (if decreased, often early morning awakening)
- Interest – decreased
- Guilt/worthlessness
- Energy – decreased or fatigued
- Concentration/difficulty making decisions
- Appetite and/or weight increase or decrease
- Psychomotor activity – increased or decreased
- Suicidal ideation
- Depressed mood most of the day, almost every day
Required Reading: Common Questions About the Pharmacologic Management of Depression in Adults
Required Reading: No Magic Pill: A Prescription for Enhanced Shared Decision-Making for Depression Treatment
Required Reading: Fatigue: An Overview
Resource: PHQ-9
