The patient is a 56 years old Caucasian female who reports to the clinic because of generalized fatigue that started 2-3 months ago. She states that the
fatigue is constant and aggravated by exertion. She denies taking any medication for fatigue and reports that there are no relieving factors. The patient
states that she feels “unproductive” and experiences reduced energy. She is alert, oriented, and corporative. She has a past medical history of HTN,
Depression, and post-menopausal status. The patient takes multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg and Calcium 500mg +
Vit D3 400IU. She is allergic to iodine. VS- Temp-98.2, P-74, R-16, BP 146/95, Height: 5’7″, Weight: 180 pounds. + Constipation Skin overall dry, hair coarse and
thick, nails without ridging + cold intolerance. Menopause status x 5 yrs. DTRs 2+ at biceps, 1+ at knees and ankles.
Differential diagnosis
Hypothyroidism: the inability of the thyroid gland to produce an adequate amount of thyroid hormone; pituitary and hypothalamus may also result in thyroid
dysfunction. The hypothalamus secretes thyrotropin-releasing hormone (TRH) that excites the pituitary gland to produce thyroid-stimulating hormone (TSH).
Thyroid-stimulating hormone stimulates the thyroid gland to create and secrete T4 and T3. Eventually, T4 is converted to T3. Change in the structure and
function of any of these organs or pathways can result in hypothyroidism (Patil et al., 2020).
Depression is a persistent feeling of sadness and loss of interest in doing activities that an individual previously enjoyed (Chand et al., 2021)
Myopathy: signs and symptoms include weakness, stiffness, cramps, and spasms. Myopathies primarily affect skeletal muscle structure, metabolism, or
channel function. They usually present with muscle weakness interfering with activities of daily living. Usually, it begins abruptly, but the usual presentation is
one of progressive muscle weakness over weeks to months. The weakness chiefly involves proximal muscle groups of the upper and lower extremities
(Nagy & Veerapaneni, 2021).
Hypothyroidism : + constipation, + cold intolerance, depressive symptoms, +5lbs weight gain in 6 months, DTRs 2+ at biceps, 1+ at knees and ankles,
tiredness, low energy.
Depression: reports worsening of depressive symptoms but thinks it is because she is so “unproductive” lately and tired all of the time. – Sleeping 8-9hrs per
night (no changes), but not feeling rested.
Myopathy Generalized weakness and intermittent muscle cramping in calves. “unproductive” lately and tired all of the time. Sleeping 8-9hrs per night (no
changes), but not feeling rested. progressive muscle weakness over 2-3 months especially in the calf.
Rank the differential in order of most likely to least likely
Hypothyroidism
Depression
Myopathy
identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be
supported with evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must
also support this decision with EBM evidence.
Hypothyroidism: serum TSH is high in hypothyroidism (Patil et al., 2020)
Depression Patient admitting to worse depressive feelings. Refer to a psychiatrist (Chand et al., 2021)
Myopathy: Serum creatine kinase (CK) is the most sensitive laboratory marker of muscle destruction a markedly elevated CK (e.g., >2000 U/L) is almost
always due to myopathy. A slightly elevated CK can also be seen in neurogenic disorders (Nagy & Veerapaneni, 2021)