Reference no: EM133218981

Case Study:

Mrs. Williams is a 68-year-old white female who presents with a complaint of fatigue that has gradually worsened over the last 6 months. The fatigue is not associated with chest pain, SOB, diaphoresis, or palpitations. She also recently noticed coldness as well as numbness and tingling in her lower extremities and intermittent dizziness when moving quickly from a seated to a standing position. She denies changes in bowel/bladder habits, denies appetite changes.

Past medical history (PMH) of measles, mumps, rubella, and chickenpox in childhood. Denies significant medical conditions. Uses occasional ibuprofen as needed for arthralgia. No surgeries or hospitalization. NKDA. Reports immunizations up-to-date, tetanus booster vaccination 3 years ago, shingles and pneumonia vaccination 2 years ago, influenza vaccination annually. Mrs. Williams's last mammogram and well-woman exam were 3 years ago, and both were normal. Natural menopause and last menstrual period 15 years ago. Denies tobacco use, alcohol consumption, illicit drug use.

Physical Exam:

• Vital Signs:?BP 126/80 supine, 118/76 sitting, 110/68 standing with reported mild dizziness, HR 82 regular, RR 14, T 98.7, Ht 5'5", Wt 135 lbs
• GEN:?Progressive fatigue that is causing her to cut down on her normal activities. Denies fever, chills, or night sweats. No acute distress
• HEENT:?Head normocephalic without evidence of masses or trauma. PERRLA, EOMs full to confrontation. Noninjected. Fundoscopic exam unremarkable with exception of pale retinal background. Palpebral conjunctiva pale. Ear canal without redness or irritation, TM clear, pearly, bony landmarks visible. No discharge, no pain noted. Pale nasal mucosa. Posterior pharynx pale with beefy red tongue. Neck: Supple without masses. No thyromegaly. No JVD
• CV:?S1?and S2?RRR, no murmurs, no gallops, no rubs
• Lungs:?Clear to auscultation
• Abdomen:?Soft, nontender, nondistended, bowel sounds present × 4 quadrants, no organomegaly, no bruits
• Back:?Nontender to palpation. No pain with forward flexion of low back but reports some mild dizziness with touching toes. No costovertebral angle (CVA) tenderness
• GU:?Normal pelvic exam
• Rectal:?Normal vault, good tone, heme-negative stool
• Neuro:?CN II-XII intact. Rhine/Weber normal, Romberg positive. Some difficulty with tandem walking. Paresthesia noted with monofilament testing of bilateral feet, DTR 1+

Questions:

• What additional assessments/diagnostic tests do you need to formulate an accurate working diagnosis?
• What differential diagnoses would apply in this case?
• Based on the data provided, what is your working diagnosis?