Case Study: Hypothyroidism, Type 2 Diabetes, and Anemia
Case Study: Hypothyroidism, Type 2 Diabetes, and Anemia
The case study describes a 56-year-old Caucasian woman who presents herself in the office complaining of fatigue that began about two to three months ago. According to the patient, the condition has worsened since its onset, and she feels not well-rested despite sleeping for eight hours daily, with no energy to perform daily tasks. Moreover, the patient attests to missing a workday two weeks ago because she could not get out of bed and has gained 5lb since her last hospital visit six months ago. The patient exhibits general weakness with intermittent muscle cramping in calves; she is also depressed with occasional suicidal or homicidal thoughts. Meanwhile, the patient has previously been diagnosed with depression, hypertension (HTN), and postmenopausal status; her family medical history constitutes various illnesses like HT, hyperlipidemia, T2DM (Type 2 diabetes mellitus), bipolar depression, anxiety, and CHF (congestive heart failure). Finally, her physical tests show she is 180 pounds in weight, 5.7′ height, 146/95 blood pressure (BP), temperature (T) at 98.2, pulse rate (P) of 74, and respiratory rate (R) of 16.
Case Study
Date of visit: November 7, 2017
A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning, you discover the following subjective information regarding the chief complaint.
| History of Present Illness | |
| Onset | “about 2-3 months” |
| Location | Generalized |
| Duration | Constant |
| Characteristics | Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well-rested. “No energy to do anything I normally can do” |
| Aggravating factors | Exertion |
| Relieving factors | None identified |
| Treatments | None |
| Severity | Denies pain; missed 1 day of work 2 weeks ago because “couldn’t get out of bed.” |
| Review of Systems (ROS) | |
| Constitutional | Denies fever, chills, or recent illnesses. +5lb. Weight gain since the last visit six months ago. |
| Eyes | No visual changes or diplopia |
| ENT | Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea. |
| Neck | Denies lymph node tenderness or swelling |
| Chest | Denies cough, SOB, DOE or wheezing |
| Heart | Denies chest pain |
| Abdomen | Denies N/V/D. + Constipation |
| Endocrine | Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs. |
| Skin | No changes in skin, hair or nails |
| Psych | Reports worsening of depressive symptoms but thinks it is because she is so “unproductive” lately and tired all of the time. -Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested. |
| Musculoskeletal | Generalized weakness and intermittent muscle cramping in calves |
| History | |
| Medications | Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU. |
| PMH | HTN, Depression, Postmenopausal status |
| PSH | Tonsillectomy |
| Allergies | Iodine dyes |
| Social | Married; Works full time as office manager of an internal medicine office; 2 kids (grown) |
| Habits | Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month). |
| FH | Maternal GM & GF deceased with CHF, T2DM and HTN;
Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM; Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and +PFO; remains anticoagulated); Oldest child (26) with seasonal allergies Youngest child (24) with Bipolar depression and ADHD, and anxiety |
| Physical Exam | |
| Constitutional | Middle-aged Caucasian female alert, oriented and cooperative |
| VS | Temp-98.2, P-74, R-16, BP 146/95, Height: 5’7″, Weight: 180 pounds |
| Head | Normocephalic, atraumatic |
| Eyes | PERRLA |
| Ears | Tympanic membranes are grey and intact, with light reflex noted. |
| Nose | Nares patent. Nasal turbinates without swelling. Nasal drainage is clear. |
| Throat | Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities. |
| Neck | Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. |
| Cardiopulmonary | Heart S1 and s2 noted, no murmurs noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema |
| Abdomen | Soft, non-tender. BS active |
| Skin | Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration |
| Psych | Mood pleasant and appropriate. |
| Musculoskeletal | Strength full throughout |
| Neuro | DTRs 2+ at biceps, 1+ at knees and ankles |
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