Multiple Complaints, No Obvious Cause in a 44-year-old Woman

She comes to your ED with a wide range of symptoms but results of her physical examination are WNL. Given her presentation, what's in your workup?

A 44-year-old woman presents to the emergency department (ED) with multiple complaints including headache, palpitations, generalized weakness, shortness of breath, pleuritic chest pain, vomiting, weight loss, sweating, dry mouth, body odor, and acne. (Fortunately she does deny a few things including abdominal pain, fever, and itchy teeth). Symptoms have been present for about 2 weeks and are all unusual for her except for the headaches, which are more common than she is used to, now occurring daily. She has a past history of migraines, seizures, vertigo, insomnia, and depression for which she takes Topomax, Lamictal, Antivert, trazadone and Wellbutrin. She admits to smoking tobacco but denies using illicit drugs.

Vital signs are: temperature 96.9°F, pulse 111 beats/min, BP 145/97 mm Hg, respiratory rate 18 breaths/min, and pulse ox, 98% on room air. Her physical examination is essentially normal except for slight tachycardia, mild sweating, and some acne. Her oropharynx does not appear dry and you do not notice any particular body odor. Lungs are clear, abdomen is benign, and there is no leg swelling.

You feel it is unlikely that you will find anything wrong with this patient, but since she has never had most of these complaints worked up in your ED before, you give her the benefit of your doubt and order an impressive slew of diagnostic tests including an ECG, chest x-ray, CBC, metabolic panel, troponin, amylase, D-dimer, UA, and pregnancy test. You also add a toxicology screen to satisfy your own suspicions. Fortunately, or unfortunately, all of her tests come back negative. You worry she won’t be satisfied without some type of abnormal test result to explain at least some of her symptoms.

Can you think of a single unifying diagnosis to explain her presentation?(Hint: Which drug reference do you use?)

For answser and discussion, please click here.

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