A 38-year-old woman comes to the office for evaluation of fatigue The patient says that she has been "beyond exhausted" for the
past 5 months since the birth of her twins. She has had difficulty keeping track of all of the new responsibilities and often forgets to
eat. She feels "disappointed" that she was unable to breastfeed despite multiple visits with a lactation consultant. The patient had a
vaginal delivery complicated by uterine atony and bleeding which required multiple transfusions. She also has a history of depression
treated with an antidepressant that was discontinued against medical advice when she realized she was pregnant. Her last menstrual
period was before her last pregnancy. Weight is 52 kg (116 lb), same as her pre-pregnancy weight. BMI is 18 kg/m2• Blood pressure
is 85/55 mm Hg and pulse is 65/min. Physical examination shows a thin, tired-appearing woman. Hemoglobin is 10.1 g/dl. Which of
the following processes is most likely the primary cause of this patient's symptoms?
QA Autoimmune destruction
0 B. lschemic necrosis
0 C. Lymphocytic infiltration
0 D. Nutritional deficiency
0 E. Psychosocial impairment
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