100 Cases in Clinical Medicine

CASE 88: FATIGUE

History

A 63-year-old woman is brought in to the surgery by her neighbour who has been wor-
ried that she looks increasingly unwell. On direct questioning she says that she has felt
increasingly tired for around 2 years. She has been off her food but is unclear whether she
has lost any weight. She was diagnosed with hypothyroidism 8 years ago and has been on
thyroxine replacement but has not had her blood tests checked for a few years. Her other
complaints are of itching for 2–3 months, but she has not noticed any rash. She says that
her mouth has been dry and, on direct questioning, thinks her eyes have also felt dry.

There has been no disturbance of her bowels or urine although she thinks that her urine
has been rather ‘strong’ lately. She is 14 years postmenopausal. There is a family history
of thyroid disease and of diabetes. She does not smoke, and drinks two glasses of sherry
every weekend. She has never drunk more than this regularly. She has taken occasional
paracetamol for headaches but has been on no regular medication other than thyroxine
and some vitamin tablets she buys from the chemist.

Examination

Her sclerae look a little yellow and she has xanthelasmata around the eyes. There are some
excoriated marks from scratching over her back and upper arms. The pulse is 74/min and
regular, blood pressure is 128/76 mmHg. No abnormalities are found in the cardiovascu-
lar or respiratory system. In the abdomen, the liver is not palpable but the spleen is felt
2 cm under the left costal margin. It is not tender.

Normal

Sodium 142 mmol/L 135–145 mmol/L

Potassium 4.2 mmol/L 3.5–5.0 mmol/L

Urea 5.6 mmol/L 2.5–6.7 mmol/L

Creatinine 84 &moI/L 70–120&mol/L

Calcium 2.24 mmol/L 2.12–2.65 mmol/L

Phosphate 1.09 mmol/L 0.8–1.45 mmol/L

Total bilirubin 84 mmol/L 3–17 mmol/L

Alkaline phosphatase 494 IU/L 30–300 IU/L

Alanine aminotransferase 63 IU/L 5–35 IU/L

Gamma-glutamyl transpeptidase 568 IU/L 11–51 IU/L

Thyroid stimulating hormone 1.2 mU/L 0.3–6.0 mU/L

Cholesterol 7.8 mmol/L !5.5 mmol/L

Fasting glucose 4.7 mmol/L 4.0–6.0 mmol/L

Antinuclear antibody:'

Antimitochondrial antibody:'''

Thyroid antibodies:''

INVESTIGATIONS

Questions

• What is your interpretation of these findings?


• What is the likely diagnosis and how might this be confirmed?