A 68 y.o. male comes to the office complaining of fatigue and weakness, which started approximately 1 month ago. Initially, the patient thought he might have a virus, but he became concerned when the symptoms persisted. He sleeps 9 hours at night and takes one to two 1-hour naps each day. He states he just can’t stay awake and reports his sleep is restorative. He has noticed mild general weakness, which is non-focal. He notices this mostly when he has tried to keep up his regular weightlifting routine at the gym.

 Past Medical History

  • HTN, 20 years poorly controlled on Toprol XL 100 mg daily
  • Overweight- BMI 26

 Family History

  • Father, died at age 75 from complications of CABG
  • Mother, 92, alive, overall good health, HTN, A-fib, osteoporosis

Psychosocial History

  • Retired. Married with two grown children. Nonsmoker; drinks one to two glasses of wine almost daily with dinner.

Review of Systems

  • General: Has lost a few pounds since his appetite is not very good.
  • HEENT: Denies visual changes; recent eye exam showed no change in prescription. Denies sore throats, frequent colds, hearing difficulties.
  • CV: BP in fair control. Admits to needing more aerobic exercise. Denies palpitations.
  • Respiratory: Denies SOB, cough, pneumonia, use of/need for inhalers.
  • GI: Appetite poor. Denies nausea/vomiting/diarrhea/constipation. 
  • GU: Reports nocturia. Last PSA normal.
  • Neuro: Denies HAs, dizziness, confusion, although admits to being forgetful.
  • Endocrine: Denies polyphagia, polyuria (except at night), polydipsia. Denies hair thinning, cold intolerance, weight gain, bradycardia.
  • Psych: Denies history of depression in family or self.

Physical Examination

  • Vital signs: BP 170/96, HR 88, RR 14, BMI 26.
  • General: Alert and cooperative, posture erect, gait study, in no distress.
  • HEENT: Thick gray hair. Facial expressions symmetrical, PERRLA, EOMs parallel, full peripheral vision. Some AV nicking seen with ophthalmoscopy. Posterior pharynx without lesions, inflammation. No cervical lymphadenopathy. Thyroid not enlarged or nodular. Weber showed no lateralization and Rinne AC greater than BC.
  • CV: RR&R, no murmurs, S3 or S4. No JVD. No carotid bruits. LE edema 2+.
  • Respiratory: Clear A&P. CXR showed no cardiomegaly, pneumonia, or other consolidations, effusions, cavitary lesions, or flattening of the diaphragm.
  • Abdomen: Protuberant. No tenderness, masses, bruits. No shifting dullness.
  • MS: Strength equal, 5/5 in all four extremities.
  • Neuro: A&O x 4. CNs II to XII intact. DTRs 2+ bilaterally, negative Romberg

Case Study Discussion – Part I:

Answer the following and post your response in the Case Study Part I by creating your own initial thread.

Identify a minimum of three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Include underlying etiology, demographics, risk factors, clinical manifestations (signs and subjects), and objective findings along with pertinent positives and negatives. Provide rationale for each differential with supporting evidence from the case study.

What further history, further physical examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions? Provide rationale and supporting evidence based resources for each further history, examination and diagnostic studies.