Approach to fatigue Quiz: Ace Your Exams

A 33-year-old woman presents to the primary care clinic for evaluation of fatigue. She feels severely fatigued on a daily basis since recovering from a viral infection about eight months ago. She also becomes tired after her usual exercise routine and is sometimes too tired to go to work the next day. She reports increased sensitivity to noise and occasional palpitations and lightheadedness when going from lying down to standing up. Temperature is 36.1°C (97°F), pulse is 90/min, respiratory rate is 15/min, and blood pressure is 125/68 mmHg. On physical examination, she appears more fatigued than at the beginning of the visit. She has 5/5 strength in all extremities. Oropharyngeal and neck examinations are unremarkable. Cardiopulmonary and abdominal examinations are unremarkable. Initial laboratory studies show hemoglobin of 14.2 g/dL and TSH of 3.6 mIU/L. Which of the following additional clinical elements is most likely to be present?