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Suggest treatment for fatigue, shoulder pain and breathing trouble

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Posted on Sat, 28 May 2016
Question: Hi, I am looking for help with diagnosis of an ongoing health issue. In particular I’d like a short-list of say 5 to 7 “most likely” diagnosis. A longer list of all the possible diagnosis is also useful to me – but most importantly I want to know which are the “first priority” illnesses to test for.

Current symptoms, for which I want diagnosis:
1.     Fatigue, especially after exercise, or following times when busy (eg working long hours). I first noticed this – just slightly – around 2012 – and it has been getting gradually worse for the last 4 years. I feel like I really crash and nowdays usually need to spend a day in bed to recover afterwards, eg after a 1 day hiking trip, or after spending 2 or 3 long days in the office. This is very a-typical for me, ie a sudden step-change in energy levels/recovery compared with all my adult life before this. Also, I very strongly don’t believe it’s age-related fatigue, because older people with a similar lifestyle to me - eg my mother - don’t have the same symptoms. To be clear, I want other diagnoses than “it’s just normal aging” – that is incorrect and no use to me.
2.     Lung issues – coughing up solid yellow chunky phlegm – mostly during exercise, and for 1 to 2 days afterwards. I first noticed this around 2013 and, like the fatigue, it’s been getting steadily worse for the last few years. Symptoms are worse if hiking fast uphill, or at high altitude. I sometimes use an inhaler (ventolin) but this seems to be less effective now than it used to be. No blood in phlegm. It hurts to cough and my lungs feel sore. In recent times the chest pain feels like it maybe extends into my right shoulder. (I’m less certain about the shoulder pain – it’s only happened rarely.)
3.     Whistling/wheezy breath, on the exhale – a sort of whistle, right at the end of exhaling. I first noticed this 6 months ago, and it happens all the time, whether I exercise or not, and whether I use ventolin or not.
4.     Ache in my spine, along my back behind my lungs. Massage along the spine feels like it helps, but this makes me cough. I first noticed this in 2014 and it’s been getting steadily worse.
5.     I tried a ketogenic diet in the last few weeks (high fat, very low sugar and carbs), and it may perhaps have made symptoms worse. I’m not sure of this though - it’s a bit early to tell.

Background:
I am 40 years old, female, sexually active in the past but not in the last 2 years, and have never had kids. Countries I’ve spent time in over the last 15 years: Canada, USA, New Zealand, and Nepal. Plus brief (<1 week) trips to South Korea, Spain, France and England. I’ve had two trips to Nepal - in 2005 and 2014 - both trips about 2 months long, travelling in remote mountain areas with poor hygiene. I’m typically quite fit, although less so in recent years due to the problems listed. My typical weekly exercise used to be 20+ hours per week of steady cardio (before these problems), nowdays average is more like 10 hours/week, at a slow pace. I work 32 hours per week in a desk job (reduced from 40 hours/week 2 years ago, due to this health issue).

Medications: The only medication I'm taking regularly is zopiclone (sleeping pills), which I've been taking for 17 months. Note that my fatigue and lung symptoms started before I started taking zopiclone, and continued regardless of whether I sleep well or not (although lack of sleep does exacerbate symptoms). For the first 15 months I averaged 1/2 pill (ie half of 7.5mg) per night, and for the last 2 months reduced to 1/4 pill per night. For the last 3 months I've been sleeping very well, but fatigue/lung symptoms continue.

History of past illness/accidents - at 4 years old I nearly died of suffocation (my heart stopped for a few minutes), and at 5 years old I had severe pneumonia. I’ve had chest infections a couple of times as an adult, and pneumonia once (a mild case).

I hope to hear back from you soon (within 12 hours, if possible).
Thanks,
xxxxxxx
doctor
Answered by Dr. Panagiotis Zografakis (1 hour later)
Brief Answer:
investigation is required...

Detailed Answer:
Hello XXXXXXX

I've read your description thoroughly. I'll try to help by presenting my ideas about the right investigation strategy. For start, I won't mention any "exotic" (meaning very rare or unlikely) diagnoses. I'll stick to the basics. I have to note that you haven't provided any test reports and I suppose (just a guess) that you have done some, because you seem to be too troubled by your current condition. So if you had any test done, please upload the report. It could provide clues (or exclude disorders).

- thyroid disease: one of the commonest presentations of thyroid disease is fatigue. Measuring the serum TSH would make things clear.
- anemia: for a young woman, having a low hematocrit wouldn't be unusual, so a complete blood count should be done to check for it. If a low hematocrit is present then ferritin, iron and TIBC would have to be done too and perhaps other tests as well, depending on the complete blood count results.
- infectious disease: the pulmonary symptoms, your trips to "areas with poor hygiene", the fatigue raise suspicions for tuberculosis or other "chronic" infections. A chest X-ray should be very helpful in that regard. Measuring your body temperature twice a day for 3 days would also help to exclude a low grade "hidden" fever.
- COPD: it would explain most of your symptoms but not the fatigue, as you've described it. Wheezing, coughing and producing phlegm are common symptoms of this condition. A spirometry is the right test to do.
- electrolyte disorders: their most likely cause is drugs' side effects but there are other potential causes. A low sodium for example may cause fatigue, nausea, etc unrelated to physical exertion.
- Sleep apnea: it's more common individuals with obesity or who smoke, snore and feel tired throughout the day like if they've not slept at all. A sleep study can be done when other - more likely - causes have been excluded.
- anxiety/depression: a very common cause when no organic diagnosis can be reached.

I don't believe that the back pain or your diet has anything to do with the rest of the symptoms - at least for start. Some conditions can be related to them but they're not common enough to mention in the first differential diagnosis list...

In any case a check-up (blood and urine tests) may provide clues to the diagnosis. If the more common conditions are excluded by the first results or by clinical examination (or - better - both) then other causes can be considered.

I hope you find my comments helpful!
You can contact me again, if you'd like any clarification or further information.

Kind Regards!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Panagiotis Zografakis (48 hours later)
Hi Dr Zografakis
Thanks very much for your answer - this is very helpful. (Just found it today sorry - my spam filter screened the email out.)
My family doctor retired around the time these symptoms started in 2013. Since then I have had a mix of different doctors which I think is part of the problem. I now have a good doctor with whom I'd arranged for blood tests - which were done today. I'm meeting with her next week to review results. I believe the tests include thyroid problems & anaemia. I will ask to also get tested for TB and COPD, and perhaps follow up other infectious diseases if all the above are negative.

What other some of the other infectious diseases I should check for (after TB)? Ie can you list a few "next most likely" possibilities?

I feel it's quite possible I caught something during my trip to Nepal in 2005. During this trekking trip I got very sick and lost 20kg, ie went from 75kg to 55kg over 4 weeks - but recovered quite well afterwards except for some ongoing digestive issues. It's possible that I picked up a bug or problem that didn't present symptoms until 2013+ (during a period of several years of stress and insomnia for me).

FYI, I've never smoked and am not particularly overweight (I am 73kg and 5'6").
Sleep apnea is unlikely, and I think anxiety/depression is a symptom not a cause. (I sometimes feel stressed or unhappy about my lack of energy to meet daily demands.) I get the same fatigue after exercise even when feeling cheerful.

Thanks again for your very useful response.
Cheers,
xxxxxxxx
doctor
Answered by Dr. Panagiotis Zografakis (15 minutes later)
Brief Answer:
the tests would be very useful...

Detailed Answer:
Hello again,

it's good to know that you've done some tests. I don't know which tests, but I'm sure that your doctor chose them wisely.

Regarding the infectious diseases, the list you're asking is not easy to form. I could mention some of them but it wouldn't be very useful for you because the doctor has to evaluate various little pieces of information to suspect or exclude them. Epstein-Barr virus for example may cause chronic fatigue. Brucella may cause a long-lasting disease although in many cases fever is present. Other viral illnesses including the "chronic" hepatitis viruses (mostly B and C), HIV, CMV, etc may also cause fatigue. The tests would help to exclude some of them indirectly, even if they've not been investigated directly with specific tests. Lyme disease could be another concern. The list may go on depending on the findings.

Regarding anxiety and depression they are diseases! You may have heard of them as "generalized anxiety disorder" and "depression" or "major depressive disorder".

Please contact me again, if you still have questions.

Kind Regards!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Panagiotis Zografakis (47 minutes later)
Thanks again Dr Zografakis for your very helpful answers.
It looks like I have 3 days until discussion closes automatically - I'll leave it open for now in case I think of any other questions, but it looks like now I should wait until I get a bunch of test results back and have discussed this with my doctor. I found this online option very helpful as the 15 minute doctor's consults always seem rushed and I don't feel I'm good at explaining the problem. (I write more coherently than I speak.)
I really liked this service; I would use it again, and recommend it to others.
Thanks!
xxxxxx
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Dr. Panagiotis Zografakis

Internal Medicine Specialist

Practicing since :1999

Answered : 3762 Questions

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Suggest treatment for fatigue, shoulder pain and breathing trouble

Brief Answer: investigation is required... Detailed Answer: Hello XXXXXXX I've read your description thoroughly. I'll try to help by presenting my ideas about the right investigation strategy. For start, I won't mention any "exotic" (meaning very rare or unlikely) diagnoses. I'll stick to the basics. I have to note that you haven't provided any test reports and I suppose (just a guess) that you have done some, because you seem to be too troubled by your current condition. So if you had any test done, please upload the report. It could provide clues (or exclude disorders). - thyroid disease: one of the commonest presentations of thyroid disease is fatigue. Measuring the serum TSH would make things clear. - anemia: for a young woman, having a low hematocrit wouldn't be unusual, so a complete blood count should be done to check for it. If a low hematocrit is present then ferritin, iron and TIBC would have to be done too and perhaps other tests as well, depending on the complete blood count results. - infectious disease: the pulmonary symptoms, your trips to "areas with poor hygiene", the fatigue raise suspicions for tuberculosis or other "chronic" infections. A chest X-ray should be very helpful in that regard. Measuring your body temperature twice a day for 3 days would also help to exclude a low grade "hidden" fever. - COPD: it would explain most of your symptoms but not the fatigue, as you've described it. Wheezing, coughing and producing phlegm are common symptoms of this condition. A spirometry is the right test to do. - electrolyte disorders: their most likely cause is drugs' side effects but there are other potential causes. A low sodium for example may cause fatigue, nausea, etc unrelated to physical exertion. - Sleep apnea: it's more common individuals with obesity or who smoke, snore and feel tired throughout the day like if they've not slept at all. A sleep study can be done when other - more likely - causes have been excluded. - anxiety/depression: a very common cause when no organic diagnosis can be reached. I don't believe that the back pain or your diet has anything to do with the rest of the symptoms - at least for start. Some conditions can be related to them but they're not common enough to mention in the first differential diagnosis list... In any case a check-up (blood and urine tests) may provide clues to the diagnosis. If the more common conditions are excluded by the first results or by clinical examination (or - better - both) then other causes can be considered. I hope you find my comments helpful! You can contact me again, if you'd like any clarification or further information. Kind Regards!