A 45-year-old man is referred to your outpatient clinic by his family physician for fatigue. He...

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A 45-year-old man is referred to your outpatient clinic by his family physician for fatigue. He reports a 2-year history of debilitating fatigue. He had a flu-like illness a couple of weeks before the onset of the fatigue, but was well prior to this. He has no significant past medical or past psychiatric history and takes no medications. He sleeps 8-10 hours per night, but does not feel refreshed in the morning. He feels "completely exhausted", and lies down for an hour every afternoon, but does not fall asleep. The fatigue is much worse after exertion, so he has stopped going to the gym. He still works, but rarely has the energy to socialize with his friends. He admits that he often feels "down" because the fatigue is not getting better. His concentration is somewhat impaired, which he attributes to the fatigue. His weight has been stable, and review of systems is, including further questioning about depressive symptoms, negative. He and his husband are goat farmers. He smokes 2 pipes a day and has 1 ounce of gin every night. A thorough physical examination is performed. He has a flat affect, but no other significant abnormal finding is detected. His family physician has sent you the results of the following investigations, all performed within the last 3 months: • CBC (including differential), electrolytes (including Ca, Mg, and PO4), creatinine, urea, glucose, liver enzymes, CK, INR, TSH, cortisol (following ACTH stimulation), CRP and ESR: all normal. Serologies for HIV, Epstein-Barr virus (EBV) and Lyme disease were negative. Blood cultures incubated for 4 weeks have been negative on 2 separate occasions. Chest radiograph revealed no abnormality. • . 2a. What further investigations, if any, would you suggest at this time? List no more than TWO. (total marks, 2) 2b. What TWO recommendations will you make regarding management? (total marks, 2) A 45-year-old man is referred to your outpatient clinic by his family physician for fatigue. He reports a 2-year history of debilitating fatigue. He had a flu-like illness a couple of weeks before the onset of the fatigue, but was well prior to this. He has no significant past medical or past psychiatric history and takes no medications. He sleeps 8-10 hours per night, but does not feel refreshed in the morning. He feels "completely exhausted", and lies down for an hour every afternoon, but does not fall asleep. The fatigue is much worse after exertion, so he has stopped going to the gym. He still works, but rarely has the energy to socialize with his friends. He admits that he often feels "down" because the fatigue is not getting better. His concentration is somewhat impaired, which he attributes to the fatigue. His weight has been stable, and review of systems is, including further questioning about depressive symptoms, negative. He and his husband are goat farmers. He smokes 2 pipes a day and has 1 ounce of gin every night. A thorough physical examination is performed. He has a flat affect, but no other significant abnormal finding is detected. His family physician has sent you the results of the following investigations, all performed within the last 3 months: • CBC (including differential), electrolytes (including Ca, Mg, and PO4), creatinine, urea, glucose, liver enzymes, CK, INR, TSH, cortisol (following ACTH stimulation), CRP and ESR: all normal. Serologies for HIV, Epstein-Barr virus (EBV) and Lyme disease were negative. Blood cultures incubated for 4 weeks have been negative on 2 separate occasions. Chest radiograph revealed no abnormality. • . 2a. What further investigations, if any, would you suggest at this time? List no more than TWO. (total marks, 2) 2b. What TWO recommendations will you make regarding management? (total marks, 2)

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