Pediatric Primary Care Case Studies (19 page)

   Thyroid function tests: T4 7.2 µg/dL (normal), TSH 1.9 µIU/mL (normal).

   Urinalysis: pH 5.0, specific gravity 1.020 and negative for nitrites, blood, sugar, bilirubin, and protein (normal UA).

   Epstein-Barr titers and heterophile antibody: negative for acute and chronic infection.

Making the Diagnosis

In order to determine if the root of Jennifer’s symptoms is behavioral or physical, it is important to understand the clinical presentations of the most common causes of adolescent fatigue. In many instances, a detailed history and physical examination are all that are needed. Laboratory testing should be used to rule out serious illness and help narrow the differential diagnosis in cases where history and physical examination data prove inconclusive.
Table 5-2
contains a list of commonly used laboratory tests with clinical indications.

Several common differential diagnoses and clinical presentations should be considered when adolescents present with fatigue. Mononucleosis, or Epstein-Barr virus (EBV) infection, is one of the most common causes of adolescent fatigue. Acute mononucleosis is characterized by marked sore throat, anorexia, anterior and posterior cervical adenopathy, fever, malaise, and myalgias. Approximately half of all cases may be accompanied by splenomegaly. Chronic mononucleosis follows acute symptoms and most often presents with marked fatigue, painful glands, and loss of appetite, although mild presentation of acute symptoms is possible (White, Sullivan, & Buchwald, 2004). Chronic EBV symptoms can last for up to 6 months following an acute episode. Positive EBV titers and heterophile antibody test (Mono Spot) indicate acute EBV infection, although up to 10% of adolescents with this disease will have a negative Mono Spot (Ozuah & Sigler, 2001). Complete blood counts indicate elevated white blood counts and may demonstrate the presence of atypical lymphocytes. In this case, Jennifer’s history, physical examination, and laboratory results are not consistent with this diagnosis. Because she has had symptoms all summer and the white blood cell counts are normal, it will not be necessary to repeat the EBV titer.

Depression impacts the lives of up to 5% of teens and is one of the most common causes of chronic fatigue (American Academy of Child and Adolescent Psychiatry, 2004; Green, 1998). The classic symptoms of depression include marked loss of interest in activities and feelings of sadness. However, also common are irritation, agitation, impaired concentration, decreased school performance, substance use, and risk taking. Jennifer does not report any of these symptoms, thus making this diagnosis unlikely.

Allergies can disrupt sleep, and many of the medications commonly used to treat allergies (especially first-generation antihistamines) cause drowsiness. Pale, boggy nasal turbinates; clear rhinorrhea; pharyngeal cobblestoning; nonexudative conjunctivitis; sneezing; and increased tearing are signs of allergic disease. Even though Jennifer does have seasonal allergies, she is not currently taking antihistamines and her physical examination does not support this diagnosis.

Anemia may occur secondary to dietary restriction (especially iron intake), infection, chronic illness, and idiopathic causes. Most older children and teens with anemia are asymptomatic, although complaints of fatigue, activity intolerance, and pallor are common. Adolescents are especially susceptible to iron-deficiency anemia because of increased metabolic needs and dietary habits. Jennifer’s CBC indicates that she is not anemic.

Behavioral causes of fatigue include excessive exercise, overscheduling, and caloric restriction. Adolescents often have busy academic lives, social obligations, sports activities, and jobs that, in combination, result in physical and mental fatigue. Adolescents are very body conscious and will commonly use caloric restriction as a means of losing weight quickly. Skipped meals, high caffeine intake that impacts sleep, and diets that are often too high in carbohydrates, both simple and complex, also cause fatigue. Jennifer’s 24-hour diet recall does not support caloric restriction as a cause of her fatigue, but her work schedule is rigorous and may be contributing to her symptoms.

Despite the need for 9 to 9½ hours of sleep each night, most teens sleep for only an average of 7 to 7½ hours (Mindell & Owens, 2003). The epidemic of fatigue caused by inadequate sleep is so great that as many as 68% of high school students report excessive daytime sleepiness (Kothare & Kaleyias, 2008). Work schedules, busy social calendars, and the need to finish school assignments often result in late bedtimes and fragmented sleep. Most high schools begin before 8:00 a.m., resulting in very early wake-up times, often as early as 5:00 a.m. (Mindell & Owens). Puberty causes increased sleep needs secondary to rapid growth and metabolic needs, and a resetting of the circadian sleep rhythms that result in teens actually becoming sleepy 2 hours later than their prepubertal peers (Mindell & Owens; Kothare & Kaleyias).

Based upon the history and physical findings in this case, the most likely cause of Jennifer’s fatigue is sleep deprivation.

Management

What additional information needs to be considered prior to making a management plan for Jennifer?

Jennifer is actively working on her adolescent developmental milestones. In her case, she has achieved some degree of independence from her parents in that they trust her to visit your office unaccompanied and allow her to schedule
her own activities fairly independently of the family. She is obviously very involved with peer relationships given her many phone, texting, and “hanging out” hours per week. Although not directly working on a future vocation, her two jobs indicate that she is working on issues related to employment—employee roles and responsibilities and financial gain. Her involvement with school indicates that she is a goal-directed young woman who is cognitively developing as predicted.

Given these characterizations, your plan will need to:

•   Acknowledge that she is the primary decision maker related to her problem, not her parents. (independence from parents developmental task)

•   Peer time needs to be assumed, though with adjustments. (peer relations task)

•   Her involvement with employment as well as school is important to maintain to some degree. (cognitive and vocational goals)

Therapeutic Management Plan

Sleep Hygiene Measures

Management of fatigue caused by poor sleep hygiene and insufficient sleep primarily focuses on behavioral modification and promotion of healthy sleep habits. Medications should be used for only brief periods of time and are not indicated for the majority of children.

The first step in forming an appropriate management plan is the determination of each adolescent’s practices that increase arousal and/or disrupt sleep cues (Mindell & Owens, 2003). Behaviors that arouse include caffeine intake, engaging in exercise in the late evening, watching television or playing video games while in bed, or trying to sleep in a nondarkened room. Behaviors that disrupt normal sleep cues include falling asleep while watching television or listening to music, spending long periods of time in bed while not sleeping, taking late naps, and sleeping in too late. Altered sleep cues are quite common during adolescence because most teens sleep too little during the work week, thus causing their “sleep clock” to be readjusted. This causes them to not feel sleepy until late evening to early morning (11:00 p.m. to 1:00 a.m.). Then, because they are so tired, they attempt to “make up” sleep on the weekends, thus resetting their sleep cycle even later. Sleep diaries are an excellent way to determine sleep patterns and behaviors and provide for greater depth of information than sleep recalls.

When you call Jennifer to give her the laboratory results, you ask her to keep a sleep diary and request a follow-up visit in 10 days. Jennifer’s sleep diary reveals that she routinely gets 5 to 6 hours of sleep on weekday nights, she naps for 4 to 5 hours on weekends, and rarely falls asleep until after midnight. Her diary also reveals that her sleep is disrupted at least twice a week by friends who call her cell phone or send text messages after 1:00 a.m.