Endocrinology Case Study

HISTORY AND PHYSICAL EXAMINATION

This 36-year-old man was doing well until 3 years ago, when he developed progressively severe fatigue.  At that time he had been in a stressful job situation.  However, these symptoms have persisted and gotten worse, although the stress has improved.  There is no relation to meals or time of day, although he is somewhat more tired in the afternoons.  He sleeps 7 to 8 hours during the week and 12 hours on weekends.  Chemistry-2, CBC, Epstein-Barr studies, and thyroid function tests have been normal.  Was tried on Thyrolar one-half grain because of low normal T4, but there was no benefit.  Has received Parnate, Nardil, and other antidepressants, including vitamin B12 injections, without any benefit.  He has a 3-year history of constant burning in the eyes.  An ophthalmologist did not find anything wrong.

REVIEW OF SYSTEMS

Has periodic dizziness particularly when standing up rapidly, occasional tinnitus, frequent constipation and occasional diarrhea, nocturia x2 or 3, cold extremities, and dry skin of relatively recent onset.  Has some anxiety and insomnia and is depressed, apparently in relation to his condition.

FAMILY HISTORY

Father has heart disease.  Brother has retinitis pigmentosa.

HABITS

Drinks coffee.  Diet is balanced and low in sugar.

PHYSICAL EXAMINATION

VITAL SIGNS:  Height 6 feet 1 inch, weight 190 pounds.  Blood pressure 130/72, pulse is 68.

HEENT:  HEENT is normal.

NECK:  Neck is normal.

HEART:  Heart is normal.

LUNGS:  Lungs are normal.

ABDOMEN:  Abdomen is normal.

PULSES:  Pulses are normal.

EXTREMITIES:  Extremities are normal.

GROSS NEUROLOGIC:  Gross neurologic examination is normal.

SKIN:  Skin is normal.

RECTAL:  Rectal examination not done.

ASSESSMENT

1. Chronic fatigue.

2. Burning eyes.

3. Depression.

4. Signs of possible hypothyroidism.

5. Constipation and diarrhea.

PLAN

We will check basal temperatures and begin thyroid prescription if low.  Gave therapeutic trial of 6-cc vitamin C, 4-cc calcium/magnesium, 1 cc of B6, B12, B5, and B complex IV.  Will repeat if helpful.  Other recommendations as noted and return in 4 weeks.

FOOTNOTE

Line 13 (Page 1).  Chem was expanded to Chemistry.  Exam was expanded to Examination.

Line 35 (Page 1).  Exam was expanded to Physical Examination.  Line 36 (Page 1).  Height and weight was added for clarity.

Lines 36-47 (Page 1).  The subheadings were added in Physical Examination to follow proper format.

Line 9 (Page 2).  Alternative:  I.V. (intravenous).  The slang term cal/mag was expanded to calcium/magnesium for clarity.