Case Study: I’m too tired to walk the dog…

Updated | Published
by SafetyNurse1968 SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

A new case study in which the patient, T.K. a 51-year-old woman who has finally taken a staycation, doesn’t have enough energy to walk her dog. You’re the CSI – read through the findings, ask questions and make your guess!

Can you solve Case Study: Feeling Exhausted?

Case Study: I’m too tired to walk the dog…

Chief Complaint

“Over the last few months I’ve been increasingly exhausted. I thought maybe I just needed some time off, but now that I’m actually taking a break from work, I’ve been feeling worse than ever. This last week I haven’t even been able to walk the dog.”

History of Present Illness

T.K. is a 51-year-old woman of mixed race who presents to her primary care provider with progressive fatigue, loss of appetite and mild nausea for the last 6 days. She has been at home for the last 5 days on leave from work but has been unable to take part in her usual activities including walking the dog and gardening. Her partner has insisted that she make an appointment with her primary care provider.

General Appearance

Looks fatigued: eyes and shoulders drooping, sighs deeply every few minutes, flat affect, moves slowly and with effort; pt appears female, skin is brown in color, appears stated age

Past Medical History

  • Broken clavicle from a fall from her bicycle, treated with surgery 10 years ago
  • Latent TB, Positive PPD 4 years ago, treatment with isoniazid (INH) for 9 months
  • High blood pressure, pre-diabetes and hypercholesterolemia for 2 years controlled with diet and exercise
  • Mild depression diagnosed 4 years ago, treated with Prozac and counseling

Family History

  • Mother had Ductal Carcinoma In Situ 15 years ago
  • Father had MI at age 65
  • One brother died from opioid overdose at age 21
  • One sister (age 45) with Graves disease

Social History

  • Born and raised in Asheville, NC
  • Works in an insurance office doing medical coding, previously had been an RN, but quit R/T latent TB
  • Partner teaches elementary school, no medical issues
  • Drinks 1-2 alcoholic beverages per week, non-smoker, occasional cannabis use, denies other drug use
  • Loves gardening and hiking with partner and dogs
  • Tries to walk daily and follows low carb, low cholesterol, low salt diet

Medications

  • Prozac 40 mg PO daily for mild depression
  • Acetaminophen 650 mg PO, every 4 hours PRN pain
  • Loratadine 10 mg PO daily for allergies
  • Benadryl 50 mg PO qhs PRN sleeplessness
  • Multivitamin, Centrum, PO daily

Allergies

NKA

Review of Systems (only abnormal systems are presented)

  • Weight loss of 10 pounds in last month
  • Salt cravings for several weeks until loss of appetite a week ago
  • Several bouts of dizziness, one fainting spell in last 6 months
  • Few aches and pains
  • Very dry skin, subnormal turgor, sparse axillary hair, pigmented skin creases on palms of hand, elbows and backs of knees
  • Breasts have very dark areolae, hyperpigmentation prominent along brassiere lines
  • Moderately weak pedal pulses (1+)

Vital Signs

BP sitting, RA96/72
HR80/min
RR12/min
T98.7oF
HT5 ft. 8 in
WT170 lbs

What else do you want to know? Feel free to ask questions and make comments below.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school

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11 Comment(s)

DowntheRiver

DowntheRiver

Specializes in Urgent Care, Oncology. Has 8 years experience. 983 Posts

I'd like to know the following:

Was a CMP, CBC, A1C, Cortisol, or ACTH drawn?

Was a ACTH stim test or hypoglycemia test done?

Any imaging?

I have a hunch, as I've seen a similar case before.

tnbutterfly - Mary, BSN, RN

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg. 155 Articles; 5,913 Posts

On 10/19/2019 at 11:01 AM, DowntheRiver said:

I'd like to know the following:

Was a CMP, CBC, A1C, Cortisol, or ACTH drawn?

Was a ACTH stim test or hypoglycemia test done?

Any imaging?

I have a hunch, as I've seen a similar case before.

Feel free to start a CSI thread in the Admin Help Desk and post your hunch. That way we will have a record of your hunch. You can always add another hunch later after more information is released.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

On 10/19/2019 at 11:01 AM, DowntheRiver said:

I'd like to know the following:

Was a CMP, CBC, A1C, Cortisol, or ACTH drawn?

Was a ACTH stim test or hypoglycemia test done?

Any imaging?

I have a hunch, as I've seen a similar case before.

I’ll be posting labs in a few days! Do you recall where you saw the other case? I’ve been working up several cases for my pathophysiology students- trying to be original and interesting!

DowntheRiver

DowntheRiver

Specializes in Urgent Care, Oncology. Has 8 years experience. 983 Posts

3 hours ago, SafetyNurse1968 said:

I’ll be posting labs in a few days! Do you recall where you saw the other case? I’ve been working up several cases for my pathophysiology students- trying to be original and interesting!

I've seen a patient with this issue before, not a case study.

Nonetheless, I think it's a great case study.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

39 minutes ago, DowntheRiver said:

I've seen a patient with this issue before, not a case study.

Nonetheless, I think it's a great case study.

Oh that’s even better! Thank you so much!

Lunah, MSN, RN

Specializes in EMS, ED, Trauma, CNE, CEN, CPEN, TCRN. Has 14 years experience. 33 Articles; 13,699 Posts

Yep, also had a similar patient in the ER. I have made a post in the admin help desk. ?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

Just now, Pixie.RN said:

Yep, also had a similar patient in the ER. I have made a post in the admin help desk. ?

Fantastic! So glad you read and commented.

sirI, MSN, APRN, NP

Specializes in Education, FP, LNC, Forensics, ED, OB. 18 Articles; 13,669 Posts

Admins have received many guesses/answers ...

If you would like to enter your guess, please do so today in the private Help Desk.

@SafetyNurse1968 will reveal more information very soon!

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

Hey there fearless CSIs! I have more information for you!

Lab and imaging results just came in - check them out and be sure to enter your guess in the private Help Desk!

Laboratory Test Results

(Fasting, drawn at 9:00 am) [only abnormal or borderline labs are presented]:

Na 125 meq/L

K 5.3 meq/L

Cl 96 meq/L

BUN 20 mg/dL

Cr 1.2 mg/dL

Glucose 54 mg/dL

Cortisol 3 ug/dL

ACTH 902 pg/mL

UA Specific Gravity 1.016

Rapid ACTH Stim test:

Pre cosyntropin cortisol 2.0 ug/dL

30 min post cosyntropin cortisol 1.9 ug/dL

Imaging:

Abdominal CT scan revealed moderate bilateral atrophy of the adrenal glands

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 45 years experience. 11 Articles; 17,417 Posts

?

Labs confirmed my diagnosis hunch.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

2 minutes ago, NRSKarenRN said:

?

Labs confirmed my diagnosis hunch.

Awesome! Thanks for playing!