38-year-old woman with increasing fatigue and dyspnea

Abstract

A38-year-old woman presented to the emergency department because of increasing fatigue and shortness of breath, worsening during the past 2 months. At the time of presentation, even minimal exertion caused her to become short of breath. She denied chest pain, cough, expectoration, orthopnea, paroxysmal nocturnal dyspnea, recent fevers, or chills. Her medical history was remarkable for a Roux-en-Y gastric bypass procedure 16 years earlier for morbid obesity. Her weight before surgery was approximately 100 kg (220 pounds), but she had lost considerable weight after surgery, with her recent weight being stable at around 57 kg (125 pounds). She had a history of frequent upper respiratory tract infections, urinary tract infections, and yeast infections since her obesity surgery. Physical examination revealed a pale woman who appeared malnourished and in mild distress. She was afebrile. The patient's vital signs were as follows: pulse rate, 110 beats/min; respiration rate, 16 breaths/min; and blood pressure, 110/70 mm Hg. Her pulse oximetry revealed normal oxygen saturation while breathing room air. A grade 2/6 systolic ejection murmur was heard over the left sternal border. Her chest was clear to auscultation bilaterally. Examination or her ear, nose, and throat was remarkable for cheilitis and glossitis. A complete blood cell count yielded the following results (reference ranges shown parenthetically): hemoglobin, 6.1 g/dL (12.0-15.5 g/dL); hematocrit, 18.1% (34.9%-44.5%); mean corpuscular volume, 104 fL (81.6-98.3 fL); white blood cell count, 1.1 x 107L (3.5-10.5 x 109/L); and platelet count, 254 x 109/L (150-450 x 109/L). She had a blood urea nitrogen level of 17 mg/dL (6-21 mg/dL), a creatinine level of 0.7 mg/dL (0.6-0.9 mg/dL), and a reticulocyte count of 2.11% (0.60%-1.83%). A differential white blood cell count revealed 66% lymphocytes (16%-52%), 19% monocytes and 11% neutrophils (42%-75%). A peripheral smear revealed mostly macrocytes, few © 2010 Mayo Foundation for Medical Education and Research.