I also need help on clinical case seven. I have some responses already but need to make sure I have answered the questions correctly.

HPI: MG is a 32-year-old female who presents to her PCP with concerns of being fatigued and feeling weak. She's also gained 30 pounds over the past three months. Endorses recurrent headaches and constipation. Having difficulty at work due to feeling like she is "thinking very slowly". She has noted that her voice has become increasingly hoarse. New edema in her face and her skin has become dry and flaky. Some swelling in her hands. Sleeping 10 hours per day. Wakes up feeling less tired, but feels like she needs a nap by noon most days.

FH/SH: Lives with spouse and one child, non-smoker, no alcohol or illicit drug use. Grant manager at the local university. Does not follow a particular diet but tries to minimize fats and carbohydrates. Walks at least 10000 steps daily based on FitBit as she is trying to lose weight "whether she feels like it or not." Parents A&W, no siblings.

Meds: Multivitamin daily, acetaminophen 500mg-1000mg prn headache

ROS: As above. Denies history of cardiac or pulmonary disease. Feels cold often.

Everything unremarkable except as follows: F in NAD, A&O x 3; VS: BP 100/64, RR 17 non-labored, P 58, T 97.6; Height 5’3"; Weight 153 lbs.

Labs and diagnostics: Labs pending

Questions

1) What is your top differential diagnosis? Please explain and justify your choice.

2) What are three other diagnoses that you could consider? Please justify your response.

3) How would you work up this patient (labs, diagnostic tests) to confirm your top differential diagnosis?

4) What findings would you expect on these labs and/or diagnostic tests?

5) How could you discern if this is a primary or secondary disorder?

The top differential diagnosis for this patient is hypothyroidism due to the presence of fatigue, weight gain, constipation, headaches, hoarseness, edema, dry skin, and feeling cold. Other possible diagnoses to consider include depression, anemia, and adrenal insufficiency. A workup for hypothyroidism would include thyroid function tests (TSH, free T4) and possibly an antibody test (TPO antibodies). Labs may show elevated TSH levels and decreased free T4 levels. If the primary disorder is suspected, additional tests or imaging may be needed to determine the underlying cause.

Based on the patient's symptoms of fatigue, weight gain, constipation, headaches, hoarseness, edema, dry skin, feeling cold, and abnormal vital signs, the top differential diagnosis is hypothyroidism. These symptoms are consistent with the classic manifestations of an underactive thyroid gland. Hypothyroidism can lead to a slowdown in metabolic processes, resulting in weight gain, fatigue, constipation, and changes in skin and hair. The presence of a low heart rate (P 58) and relatively low blood pressure (100/64) also suggests a possible thyroid hormone deficiency.

Three other diagnoses to consider include depression, anemia, and adrenal insufficiency. Depression can present with fatigue, weight changes, and difficulty concentrating. Anemia may cause fatigue, pale skin, and shortness of breath. Adrenal insufficiency can result in fatigue, weight loss or gain, low blood pressure, and electrolyte imbalances.

To confirm the top differential diagnosis of hypothyroidism, the patient should undergo thyroid function tests, including serum TSH and free T4 levels. Elevated TSH levels and decreased free T4 levels would support the diagnosis. Additionally, an antibody test (TPO antibodies) may be performed to determine if the hypothyroidism is due to an autoimmune condition such as Hashimoto's thyroiditis.

Differentiating between primary and secondary hypothyroidism would require further evaluation. Primary hypothyroidism is caused by dysfunction of the thyroid gland itself, while secondary hypothyroidism results from a malfunction of the pituitary gland or hypothalamus. Additional tests or imaging, such as a pituitary MRI or TRH stimulation test, may be needed to determine the underlying cause.

Learn more about hypothyroidism here:

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