College

**Clinical Case:**

- **Patient:** 59-year-old female
- **Chief Complaint:** Fatigue for one month

**History of Present Illness (HPI):**

- Gradual onset over the past month
- Increased fatigue and reduced tolerance to activity
- No recent illness, medication changes, or new physical activities
- History of walking 30 minutes, 5 times a week; unable to cover the usual distance
- No changes in diet or recent travel
- Sleeps an average of 7 hours but doesn't feel rested
- Does not snore or wake up at night
- No new stressors in life or work
- Overall feels healthy
- Last physical examination was 7 months ago

**Past Medical History (PMH):**

- GERD for 5 years
- Overweight
- Denies history of hospitalizations or surgeries

**Medications (Meds):**

- Omeprazole daily for 5 years
- Multivitamins + calcium as needed

**Family History (FH):**

- Mother alive at 89 with dementia
- Father deceased at 78 due to myocardial infarction
- Brother, age 56, with hypertension

**Social History (SH):**

- Divorced, full-time financial advisor
- Lives in a single-family home
- Two children (ages 33 and 36) living away
- Smoking history from ages 15 to 39
- Consumes 3 glasses of wine per week
- No history of illicit drug use
- No known drug allergies (NKDA), environmental, food, or material allergies

**Review of Systems (ROS):**

- **General:** No fevers, weight changes, night sweats; positive for fatigue
- **Skin:** Denies rashes or changes in skin lesions
- **HEENT:** Denies vision changes, eye discharge, nasal congestion, sneezing, hearing changes, or ear pain; reports a sore throat
- **Cardiovascular:** Denies chest pain; occasional heart palpitations
- **Pulmonary:** Denies cough; occasional shortness of breath
- **Abdomen:** Denies abdominal pain, nausea, vomiting, constipation, or diarrhea; bowel movements are formed and brown
- **Musculoskeletal/Neurological:** Denies joint pain, loss of range of motion, numbness, tingling, or changes in sensation
- **Psychiatric:** Denies depression, anxiety, or mood disorders

**Physical Examination (PE):**

- **General:** Alert, overweight adult female, in no acute distress
- **Vital Signs (VS):** BP 140/88, Pulse 96, Respiratory Rate 16, Temperature 98.6°F, Height 64 inches, Weight 170 lbs, BMI 30
- **Skin:** Dry, intact, without lesions
- **HEENT:** PERRLA, eyes clear without discharge, tympanic membranes intact, ear canals clear, mouth moist without lesions, tonsils 2+ with no erythema
- **Cardiovascular/Lungs:** Regular rate and rhythm (RRR), no murmurs, rubs, or gallops (MRG), clear to auscultation bilaterally (CTAB)
- **Abdomen:** Soft, round, non-tender to palpation

**Point-of-Care Testing:**

- **Hemogram:** Hemoglobin 9.6

**Other Labs:**

- RBC: 3.2
- H/H: 9.6/27
- MCV: 70
- MCH: 22
- Iron: 20
- Ferritin: 9
- B12: <200
- Folate: 5.1 nmol/L

---

**Tasks:**

1. **Create a list of three to five differential diagnoses.**

2. **Explain, for each differential diagnosis, what in the presentation, HPI, or PE supports it.**

3. **Create a pathophysiology flow chart:**

- Compare and contrast two diagnoses by documenting how they are similar and different based on symptoms, physical examination findings, and lab results.

4. **Write a brief paragraph or list:**

- Indicate what your differential diagnoses list could include if the patient were (1) 79 years old or (2) a 25-year-old patient who is pregnant.

Answer :

Differential diagnoses for a 59-year-old female with fatigue include Iron Deficiency Anemia, Vitamin B12 Deficiency Anemia, and Hypothyroidism. Common lab results and symptoms help distinguish these conditions. Alternative diagnoses would vary based on age and pregnancy status.

1. Differential Diagnosis

  • Iron Deficiency Anemia
  • Vitamin B12 Deficiency Anemia
  • Hypothyroidism

2. Explain Each Diagnosis

  • Iron Deficiency Anemia: The patient has low hemoglobin (9.6), low RBC (3.2), low MCV (70), low MCH (22), low ferritin (9), and low iron (20), consistent with iron deficiency anemia. The gradual onset of fatigue and pallor is common.
  • Vitamin B12 Deficiency Anemia: The patient's B12 level is less than 200, which is below normal, indicating B12 deficiency. Symptoms such as increased fatigue and impaired concentration fit this diagnosis.
  • Hypothyroidism: Even though not explicitly measured here, hypothyroidism can cause fatigue, weight gain, and dry skin, which some of the symptoms pointing towards hypothyroidism.

3. Pathophysiology Flow Chart

Iron Deficiency Anemia:

Insufficient iron → Decreased hemoglobin production → Decreased oxygen delivery → Fatigue

Vitamin B12 Deficiency Anemia:

Deficient B12 intake/absorption → Impaired DNA synthesis in RBCs → Megaloblastic anemia → Fatigue

Comparison:

  • Both conditions involve anemia leading to reduced oxygen delivery to tissues, resulting in fatigue.
  • Symptoms overlap: fatigue, pallor, and possibly occasional shortness of breath.
  • Differences include specific lab values (i.e., low MCV in iron deficiency vs. high MCV in B12 deficiency).

4. Differential Diagnoses for Different Ages

  • If the patient were 79 years old, differential diagnoses could include Parkinson's Disease, Heart Failure, or Chronic Kidney Disease.
  • If the patient were a 25-year-old pregnant woman, differential diagnoses could include Gestational Diabetes, Anemia of Pregnancy, or Thyroid Disease.

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