Case title : Fatigue and Chronic fatigue syndrome

Case : A 40 years woman complain since 5 months ago never has enough energy to do her routine
daily activity.
Mrs. Rita is a 40-year-old who presents to General Practitioner. She states that she "can hardly do
anything on her own any more". She complains since 5 months ago never has enough energy to do even
her routine things such as cleaning her house, cooking the meals and going shopping. "I feel tired when I
wake up and as soon as I try to do too much I become absolutely exhausted and some times I feel
dyspnoe /difficult to take a breath.
Mrs. Rita tells you that eats not to well and her body weight is slight decrease about 4 kilos in 4 months,
she felt loss of appetite. She told has any problems with her bowels, some times she got diarrhea 1- 2
times a day and remember at least 3 times in a week having had dark stools.
1.Identify Mrs. Rita's problems
2.Generate hypotheses which account for one or more of Mrs. Rita's problems.
On physical examination: Quite pale , Height : 160 Cm, Weight : 46 kg., Blood pressure 130/70. Pulse rate
104 / minute. On abdomen examination: Liver: un palpable, Spleen: Splenomegaly S II, her abdominal
was protuberant with fluid wave and shifting dullness. Thorax examination : Heart : arrhythmia. Lung :
Normal . Extremity : edema in both lower extremity.
3.What the next examination to prove or disprove the hypothese ?
4.What questions do you ask to the patient to find cause of psychiatric disorders ?

The results returned for the laboratory tests are as follows:

Hematology :
RBC

2.1 x 1012/L

(4.0-5.2 x 1012/L)

Hemoglobin

6,6 g/dL

(12 - 16 g/dL)

Hematocrit

20 %

(35 45 % )

MCV

74 fL

(82.0-98.0 fL)

Reticulocytes

140 x 109/L

(35-140 x 109/L)

Platelet count

151 .000/mm3

(150 400.000/mm3)

WBC

6800 /mm3

(5000 10.000 /mm3)

Differential

0 % basofil

( 0 1 %)

2% eosinophils

(1-3%)

0 % rod

( 2 6 %)

58% segmented neutrophils

(50-60%)

39% lymphocytes

(20-40%)

1% monocytes

(2-6%)

SGOT/AST

32 U/L

(< 40 U/L)

SGPT/ALT

27 U/L

(<40 U/L)

Random glucose

110 mg/dL

(100 - 140,mg/dL)

ESR

9 mm/min

(< 15 mm/min)

Ca

9,5 mg/dL

9 10,5 mg/dL

Clinical Chemistry

Phosphate

4 mg/dL

(3 4,5 mg/dL)

Alkali Phosphatase

90 U/L

(30 -120 U/L)

Protein Total

6,0 g/dL

(5 ,5 8 g/dL)

Albumin

2,6g/dL

(3,5 5,5 g/dL)

Globulin

3,4 g/dL

(2,0 3,5 g/dL)

Na

140 meq/L

(136 145 )

4,0 meq/L

( 3,5 5,3)

Cl

100 meq/L

( 98 106 )

Uric acid

5,5mg/dL

(2 6 mg/dL)

Urea Nitrogen

14 mg/dL

10 20 mg/dL)
(0,5 1,5 mg/dL)

Creatinin

1,0 mg/dL

Serology
Neg

Anti HIV

-(Neg)

Anti HCV

+(Pos)

HBsAg

-(Neg)

Neg

TSH

2,0 mU/L

(0,5 4,7)

T3

90 ng/dL

Urinalysis

Bilirubin + (Pos)

-( neg)

Urobilinogen ++(Pos)

+(pos)

Protein : - (Neg)

- (neg)

Glucose : - ( Neg)

-(neg)

Blood : - (Neg)

-( neg)

Neg

(60 180)

Stool benzine

Ketone : - (neg)

- (neg)

Nitrit : - ( neg)

- (neg)

Leukocyte : - ( neg)

- (neg)

+ (positive)

-(neg)

5. What your conclusion according the lab result ?

6.To determine type of anemia what examination do you need ?
7.According Periferal blood smear , Serum Iron and TIBC result what type of anemia ?
8.What another examination do you need to find another disorders ?
9.After all examination what your diagnose ?
10 What the treatment for this patient ?