Gastroenterology Case Study

-->

INITIAL OFFICE EVALUATION

After a trip to Mexico she developed diarrhea which resolved after about 2 months.  However, her stools are now not as firm as before, and she has periodic lighter color of the stools.  Also gets periodic constipation now.

She previously had a bowel movement after supper every night but not since this trip.  Has a 6-month history of nocturia x1 with no history of the same in the past.  Has lost 7 pounds in the past year.  Has a 2- or 3-year history of fatigue which got worse after pneumonia.

         

Blood work demonstrated previous mononucleosis.  CMV was positive.  Thyroid functions were normal.  ASO titer was positive.  Epstein-Barr nuclear antigen was positive at 1:40.  Chemistry profile was normal.  Sedimentation rate normal.  A diagnosis of chronic fatigue syndrome was made.

Over the past fall and winter, she had severe fatigue and achiness in the elbows, knees, ankles, and calves.  The aching has improved but still has considerable fatigue.  She works near where there are numerous foul odors.  Her building is a closed environment without windows.  She took Shaklee vitamins in the past and did have mild to moderate improvement in her symptoms.

MEDICATIONS

None.

PAST MEDICAL HISTORY

Myomectomy for fibroids.  Pneumonia.  Duodenal ulcer which subsequently healed.  Auto accident resulted in problems with the right upper area of the back.

ALLERGIES

SULFA AND ROOT BEER.

REVIEW OF SYSTEMS

Gets sinus headaches and other headaches.  Has lumpy breasts which have been checked by a gynecologist.  Has some indigestion and bloating after meals.  Has some insomnia and gets yeast infections several times a year.

FAMILY HISTORY

Unremarkable.

HABITS

Negative.  Diet balanced and low in sugar.

PHYSICAL EXAMINATION

Examination essentially normal with exception of very slight underweight.

ASSESSMENT

1. Fatigue.

2. Weight loss.

3. Change in bowel habits.

4. Nocturia x1.

5. Positive tests for CMV, ASO titer, and EBNA, with diagnosis of chronic fatigue syndrome.

6. History of pneumonia x2.

7. Possible toxic work environment.

PLAN

In view of her previous response to vitamins, will use recommendations on enclosed note.  Consider elimination diet or basal temperature tests if no improvement.  Return in 6 weeks.

FOOTNOTE

Line 21 (Page 1).  Chem was expanded to chemistry.

Line 4 (Page 2).  Exam was expanded in the title.

Line 13 (Page 2).  The word titer was added for completeness.  Alternative:  Expand the abbreviations, although in an office chart note such as this, it is not necessary.  CMV (cytomegalovirus), EBNP (Epstein-Barr nuclear antigen).

Line 16 (Page 2).  The dictated number 8 was changed to 7 for proper enumeration.