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Case Study

Headache, decreased concentration, and irritability in a 37-year-old silk screener

A 37-year-old woman who is 4 months postpartum is seen at your office with complaints of headache, increasing irritability, and difficulty concentrating. She states that she has become impatient and short-tempered with her husband and new child; minor things make her angry. These feelings began about 1 month ago. She is most aware of them in the evenings, when they are sometimes accompanied by a throbbing frontal headache. She has no psychiatric history but admits to drinking 3 ounces of alcohol a day since being married, 4 years ago. She did not drink during the pregnancy and denies using other drugs or medications. She has had no trouble sleeping.

Two weeks ago the patient and her family visited her parents for a week. During that time she felt well; the irritability and headaches subsided. Since coming home last week, however, the symptoms have returned.

The patient is worried that something in the home is causing her symptoms. She reports that the house was sprayed for termites 2 years ago, but she does not remember the name of the fumigant used. Her husband feels fine and has not been ill. Her infant daughter’s delivery was uneventful and the baby appears to be developing normally but has been “very fussy” lately. The infant, whom you saw 5 weeks ago for otitis media, is still breast-feeding.

A month ago the patient returned to her job as a word processor, working mornings and relaxing with her hobby, silk screening, in the afternoon. She gets along well with her employer and fellow employees, and the job is not generally stressful. However, she is concerned that a loss in typing accuracy and a decreased ability to concentrate may lead to conflict with her supervisor. The patient has no symptoms of postpartum depression and had no history of headaches before she resumed these activities.

On physical examination you find a slightly overweight woman with blood pressure of 125/85. Pulse is 68 and regular. She is afebrile. Her nail beds are pale. There are no skin rashes, lesions, or stigmata of liver disease. The conjunctiva are mildly injected, but the nares and oral mucosa are not swollen or injected. The thyroid is not enlarged, and no lymphadenopathy is present. There is no focal muscle tension or tenderness. There is no hepatomegaly; examination of the abdomen is unremarkable. Neurologic examination is within normal limits. Recent and distant memory are intact, proverb interpretation is normal, and she is able to do serial 7s. Sensory and motor examination are normal, as are Romberg test and gait. Deep tendon reflexes are normal and symmetrical.

(a) What should be included in this patient’s problem list?


(b) What further information would assist in establishing a diagnosis?


(c) What laboratory tests would you order for this patient?


Answers to the Pretest can be found on page 18.

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