Chronic fatigue

Patient ID: Sex:Female Age:30 Nature of work: Stay-at-home-mom/Part-time housekeeper Habits: ??


Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experience and happenings.

1. Describe your main suffering? State the correct location of pain or suffering.--Biggest complaint is fatigue, for 2 years. Also, low back pain for 5 years. Brain fog, depression, headaches, all for 2 years. Sore breasts from ovulation to menstruation. Candida-sometimes vaginal yeast, a fungal rash on right leg, tinea versicolor.

2. What other physical sufferings do you have in your body? --Lyme disease, Epstein-Barr virus, high estrogen levels, hypothyroidism, adrenal fatigue

3. What mental sufferings / feelings do you have associated with your physical sufferings? depression, brain fog

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words. --Exhausted. Some times its a jittery exhaustion, other times its like a weight on my chest holding me down. It's worse in the morning after waking. My brain feels foggy and its difficult to get out of bed.

5. When did it all start? Can you connect it to any past event or disease? What was happening in your life just before these symptoms were noticed? In Sept 2013, my preteen son was having a difficult time in school. I pulled him out to homeschool him, which caused a rift between myself, my husband and my step-daughter. I was also too tired to take him places and guide his education, so I sent him back to school after just a few weeks, expecting my symptoms to resolve. They never got better. Over the past 2 years, I have taken many supplements and had a lot of tests run and I have been able to improve many of my symptoms but the fatigue remains.

6. What time of the day do you suffer the most? What time of the day /night do you feel most energetic and happy? I feel worst in the morning. Some days I feel good in the afternoon, others in the evening and others I feel terrible all day.

7. What are the things that aggravate your suffering and those that ameliorate the same? Example: time, hot or cold application, pressure, rubbing, washing, eating, tight clothing, sweating, walking, climbing, stool etc.--Being around people a lot or exerting myself mentally or physically make me more fatigued. Showers and sugary foods improve my symptoms.

8. Do you think your sufferings have direct relation to any particular external factor or are it something to do with your own biological changes? --I think my lyme disease and epstein-Barr virus are the main cause.

9. When do you feel better, during hot weather or cold weather, humid or dry weather? I feel best during hot, dry weather.

10. Describe your general mental set up? Please pick out the adjectives which best describe your personality; (at least 10) ---Shy, Worrying, Unsocial, Emotional, Timid, Insecure, Feminine, Empathetic, Introverted, Weepy----
Nervous, Anxious, Shy, Worrying, Paranoid, Proud, Unsocial, Guilty, Depressed, Hypochondriac, Untidy, Weepy, Emotional, Impractical, Confused, Suspicious, Jealous, Timid, Aggressive, Headstrong, Forgetful, Follower, Insecure, Immature, Impulsive, Rigid, Restless, Feminine, Empathetic, Introverted.

- How do you feel before or during a thunderstorm? --Pretty calm, as long as it doesnt get too loud.

- How do you respond to consolation during your tough times? If its from my loved ones, I appreciate it. I feel like they don't care usually, so I like to see them make an effort and let me know they care about me. From people I don't know well, I generally feel uncomfortable.

- Are you sensitive to external stimuli like smell, noise, light etc.? --Yes, noise especially, sometimes light.

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc? --I dont think so
- How do you get along with your friends, family, your children and especially your husband / wife? --I havent gotten along with my husband on many occasions since getting sick. He isnt very comforting or affectionate so I feel he doesnt care. I fight with my 2 teenagers a lot because they are at such difficult ages and I'm too exhausted to deal with it. I also have a 4 year old daughter who I usually get along well with, but sometimes get exasperated with due to my fatigue. I dont have issues with others too often, as I dont get close to too many others and I tend to not speak up if anything bothers me.
-What is your profession? Do you love your profession? What is your dream job? I am a stay at home mom, soon to be homeschooling my 4 year old, which is pretty much my dream job. I love being with her, though I do need breaks more often than I get. I recently started cleaning houses a couple days a week, which I am enjoying thus far, though it does take a lot out of me, leaving me physically and mentally drained in subsequent days.
-Did you have any bereavement in life? How has it affected you? Only as a 7 year old child, when I lost my grandmother. I was upset then, think I'm ok now, though it does still upset me at times, as I was very close to her, and not close to my other grandmother, who only recently passed away. It feels unfair to have lost the one that took an interest in me and could have been there to help me through the hard times over the years.
-Do you have any issues regarding your parenting by guardians? I assume this means as a child? My parents divorced when I was 8, then got back together but there was a lot of fighting then. Then my mother moved out when I was a teen, due to my brother getting a girl pregnant and them needing a place to live and I felt like our family really split then. I felt pretty alone and unloved as a teen.
-Can you remember any unfortunate incident in life that you want to forget? Most of my relationship with my sons father. He was abusive to myself and my son and still haunts my dreams rather often.
-How do you respond to music? Do you feel better or worse mentally listening to music? Better generally.
- What upsets you most in yourself and in others?--My own insecurity and others being aggressive and careless with my emotions.

11. What are your fears and do you dream of any situation repeatedly? My fears are my children passing away or myself. I dream about my sons father trying to take him away or hurt me.

12. What do you crave in food items and what are your aversions? I crave sweets like candy, ice cream and soda, fruit and fast food-bread, fries, potatoes,greasy food. I dont like peppers, onions, zucchini, broccoli, squash...

13. How is your thirst: Less, Normal or Excessive? Normal

14. How is your hunger: Less, Normal or Excessive? Normal

15. Is there any kind of food which your body can’t stand? No.

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs? Normal-armpits and crotch

17. How is your bowel movement and stool type? Do you have any abnormal smell in the urine? I tend to be constipated unless I take supplements for it-magnesium, sea salt, etc. No abnormal urine smell.

18. How well do you sleep? Do you have a particular posture of sleeping? Well, generally. On my left side with my leg over a body pillow.

19. Do you think you are able to address your libido in general? Would you say your drive is low, normal or high? Its lower than I would like but not too bad.

20. Do you have any strange, peculiar or unusual sensation, thoughts or feelings? How are you different from others? I dont know

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication? Thyroid meds have helped a lot with my depression and joint pain. I have tried sea salt and vitamin C to treat my lyme disease but it seems to stress my kidneys, as I get low back pain.

22. What major diseases have run in the family in the last two generations both sides? My maternal grandmother died of lung can cer. My paternal grandparents died of heart attacks.

23. Describe your overall appearance with respect to your BMI, skin type, muscular or flabby etc. I am 5'1" 125 lbs. I have gained some weight since getting sick. I am mostly thin but have gained fat in my belly and butt.
24. What major diseases have you had in your life and when. Please write them in a chronological manner. Lyme disease
(For Females)
25. If your menstrual cycles are not normal, please describe all irregularities, like pains, moods, flow type, clots etc. as below: --Just breast pain from ovulation to menstruation.
- Are your periods generally regular, early or delayed? What is the usual cycle duration? Regular. My cycles are about 34 days, with 5 days of bleeding.
- Describe the sensations and locations of pain before, during and after the flow. Breast pain before.
- How do you generally deal with your sufferings during periods? Do you have any non-medical way of relieving your suffering? I just deal with it. I'm trying iodine supplementation to ease it.
- What is the duration of flow? Is it heavy, medium or light? 5 days, medium
- Do you observe clots? Yes
- Do you have mid-cycle spotting? What are the days you have spotting? No
- Describe changes in your mental condition or any other peculiar symptom that surfaces before, during or after the flow. N/A
- Do your sufferings increase or decrease as soon as the flow begins? My breast pain goes away but my fatigue and mood are unaffected.
- Did you ever take birth control pills on a regular basis? Yes, for many years. Not currently. Currently have copper IUD.
- Have you ever been treated earlier or recently for any gynecological irregularity? Please describe. No