Woman Who Has Felt Unwell for Many Years

A 41-year-old woman presents as a new patient, with complaints of chest pain and palpitations that occur intermittently and are not associated with activity, meals, or position. She says these symptoms have been present for some time, and she expresses frustration that her previous physician was unable to find their cause or to ameliorate them.

HISTORY AND REVIEW OF SYMPTOMS
To investigate her chest pain and palpitations, her last physician ordered an ECG, a dobutamine(Drug information on dobutamine) echocardiogram, and a chest radiograph; results of all of these were unremarkable. She was also referred to a gastroenterologist, who ordered an esophagogastroduodenoscopy; results of this study were normal as well. The primary care physician told her there was no physical cause of her symptoms and prescribed lorazepam(Drug information on lorazepam), but the regimen had no effect.

The patient has been feeling unwell for 12 years, although before then she was healthy. During this time, she has seen 11 different primary care providers and consulted multiple specialists. She has had 2 normal pregnancies and a tubal ligation. She last saw her gynecologist 2 months ago; results of a Papanicolaou test and mammogram were normal. She takes no medications other than a multivitamin; she has no known drug allergies. She is a social drinker (1 to 2 glasses of wine on a weekend) and does not smoke. She works as a manager of a law office and states that her symptoms have begun to affect her job performance.

Review of symptoms reveals that the patient has had similar symptoms at other times in the past. In addition, she has had episodes of “bowel problems,” headache, and insomnia; however, she has been told that evaluations for these problems revealed no abnormalities.

PHYSICAL EXAMINATION
This well-appearing woman looks her age; height is 1.63 m (64 in) and weight, 65 kg (143 lb). Temperature is 36.9°C (98.4°F); heart rate, 80 beats per minute; respiration rate, 12 breaths per minute; and blood pressure, 110/ 72 mm Hg. Head, eyes, ears, nose, and throat are normal. Neck is without thyromegaly or lymphadenopathy. Lungs, heart, and abdomen are normal. Skin is without lesions. Results of a neurologic examination are unremarkable.

LABORATORY STUDIES
Results of diagnostic studies done in the past year— including a comprehensive metabolic panel, lipid panel, thyroid-stimulating hormone measurement, urinalysis, and cardiac and GI evaluations—were all normal. Most recently, hemoglobin level was 11.4 g/dL; hematocrit, 39.6%; and mean corpuscular volume, 74 fL.

Which of the following is the most likely cause of the patient’s symptoms?
A. Chronic fatigue syndrome.
B. Fibromyalgia.
C. Somatization disorder.
D. Adrenal insufficiency.

(Answer and discussion on next page.)