First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 33. 46-Year-Old Man with Fatigue

Doorway Information

Opening Scenario

Gary Mitchell, a 46-year-old male, comes to the office complaining of fatigue.

Vital Signs

BP: 120/85 mm Hg Temp: 98.2°F (36.8°C)

RR: 12/minute

HR: 65/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 46 yo M.

Notes for the SP

 Look sad, and don’t smile.

 Speak and move slowly.

 Start yawning as the examinee enters the room.

Challenging Questions to Ask

 “I think that life is full of misery. Why do we have to live?”

 “I am afraid that I might have AIDS.”

Sample Examinee Response

This patient clearly has more to say. Silence is appropriate here, or the patient should be subtly encouraged to continue. Alternatively, you can say, “It sounds as though you’re losing hope. Have you thought about hurting yourself or tried to do so?” Or “Tell me more about your concern about AIDS. Everything that you tell me is confidential and will not leave this room.”

Examinee Checklist

Building the Doctor-Patient Relationship


 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

 Examinee explored the SP’s concern about AIDS (eg, “Tell me more about that.”).

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.


 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

 Follow-up tests.

 Lifestyle modification (diet, exercise, relaxation techniques, smoking cessation).

 Safe sex practices.

 HIV testing and consent.

 Depression counseling:

 Sources of support (eg, trusted friends and loved ones) and information about community groups.

 Possible need for referral to a psychiatrist.

 Suicide contract (ie, contact your physician or go to the ED for any suicidal thoughts or plans).

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mr. Mitchell, it appears that your life has been very stressful lately, and my suspicion is that you may be clinically depressed. Before I make a definitive diagnosis, however, I would like to order some blood tests, including one for HIV, as you have risk factors for sexually transmitted diseases. Once we have completed these tests, we should have a better idea of what is causing your fatigue. In the meantime, I strongly recommend that you quit smoking, exercise regularly, and participate in activities that you find relaxing. I would also like you to promise me that if you feel like hurting yourself, you will call someone who can help you or go immediately to an emergency department. Do you have any questions for me?


HPI: 46 yo M c/o fatigue x 3 months.

 Fatigue began after unsuccessful attempt to save his friend after a car accident.

 Constant fatigue throughout the day.

 Low energy.

 Decreased concentration that is negatively affecting job as accountant.

 Decreased appetite, but gained 6 lbs over 3 months.

 Multiple awakenings and difficulty staying asleep due to recurrent nightmares about accident.

 Feels sleepy throughout the day.

 Feelings of being depressed and helpless.

 Passive suicidal ideation but no suicide plans/attempts.

 Cold intolerance.

 Hair loss.

 Loss of interest in sex.

 No constipation.

ROS: Negative except as above.

Allergies: NKDA.

Medications: None.

PMH: Urethritis (possibly chlamydia), treated 5 months ago.

PSH: None.

SH: 1 PPD for 25 years, 2 beers/month. History of unprotected sex with multiple female partners. FH: Noncontributory.

Physical Examination

Patient is in no acute distress, looks tired with a flat affect, speaks and moves slowly.


HEENT: No conjunctival pallor, mouth and pharynx WNL.

Neck: No lymphadenopathy, thyroid normal.

Chest: Clear breath sounds bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nondistended, nontender, @ BS, no hepatosplenomegaly Extremities: No edema, normal DTRs in lower extremities.


Patient Note Differential Diagnoses

Fatigue is a common, nonspecific complaint with many etiologies ranging from simple overexertion to serious diseases such as cancer.

 Major depressive disorder (MDD): This patient meets the criteria for the diagnosis of MDD, exhibiting many classic symptoms. The mnemonic SIG E CAPS helps recall these symptoms: Sleep disturbance, decreased Interest, feelings of Guilt (worthlessness), decreased Energy (fatigue), decreased Concentration/Cognition, change in Appetite/weight changes, Psychomotor agitation or slowing, and Suicidal ideation. In order to meet the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a patient must report at least five of the above symptoms, including depressed mood or anhedonia as one of the five, for two weeks, and symptoms must significantly impair daily functioning.

 Hypothyroidism: This should be ruled out in a patient with fatigue for months. The patient’s cold intolerance, hair loss, and weight gain are additional nonspecific symptoms that suggest this diagnosis.

 Posttraumatic stress disorder (PTSD): PTSD usually occurs within three months of the traumatic experience, and the duration of symptoms is longer than a month. DSM-5 criteria include a history of exposure to a traumatic event that meets specific requirements and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Although this patient has many of the symptoms of PTSD (nightmares about the trauma, decreased concentration, anhedonia, negative mood, and difficulty staying asleep), he does not avoid stimuli related to the accident and therefore does not meet the full criteria at this time.

Additional Differential Diagnoses

 HIV infection: Given his history of STDs and unprotected sex with multiple partners, this patient should also be tested for HIV. However, it is highly unlikely that HIV infection accounts for his current depression (unless there are frontal lobe lesions due to infection or malignancy).

Diagnostic Workup

 TSH: A screening test for hypothyroidism.

 CBC: To rule out anemia.

 HIV antibody: To rule out HIV infection.

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