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Woman With Nonspecific Fatigue: Depression? Thyroid Dysfunction? Cancer Recurrence?

Woman With Nonspecific Fatigue: Depression? Thyroid Dysfunction? Cancer Recurrence?

A 34-year-old woman presents with the sole complaint of fatigue that has come on gradually over the past 6 months. She works as a schoolteacher and says there has been no change in the demands of the job. She is sleeping well and is happy in her marriage. She and other family members had a viral syndrome 4 months earlier, but none of them are feeling this fatigue. She denies fever, chills, nausea, or vomiting. She has gained approximately 5 lb recently, which she attributes to her lack of energy to exercise.

The patient had nodular sclerosing Hodgkin disease 4 years ago. The disease was limited to the chest and was treated with radiation and chemotherapy. Her oncologist told her at a visit 8 months ago that there was no evidence of disease. 

The patient shows no signs of acute distress but she appears slightly pale. Her blood pressure is 125/90 mm Hg; heart rate, 65 beats/min; and temperature, 36°C (97.4°F). There is no evidence of lymphadenopathy. Examination of the heart, lungs, and HEENT reveals no abnormal findings. There is trace edema in the lower extremities. The WBC count is 4500/µL (normal range, 4500 to 11,000/µL); hemoglobin level, 11.2 g/dL, with a mean corpuscular volume of 84 fL (normal range, 80 to 100 fL); and normal differential and platelet count. Electrolyte balance and kidney and liver function are normal.

What diagnostic clues do the history, physical, and laboratory results offer, and which of the following would be your next step?

A.   Refer her back to her oncologist
B.  Obtain a TSH level
C.  Start antidepressant therapy 
D.  Diagnose fibromyalgia and chronic fatigue and begin treatment with NSAIDs 
E.  Refer her for a bone marrow biopsy

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