Chronic lethargy in a 68 yo woman

Review of Systems

  • General: The patient says she feels tired all the time and is usually cold even now during the summer. She has a poor appetite but has gained 5 kg in weight in the preceding 4 mo despite decreased appetite. No fever, chills, headache, or body aches.

  • Skin: Her skin has become dry, and her hair is now coarse and sparse. No rash or itching.

  • HEENT: She reports fullness in her throat, and her daughter has noticed that her mother’s voice has become hoarse and her face appears puffy, particularly around the eyes. No difficulty swallowing.

  • Pulmonary: The patient reports new exertional shortness of breath and needing to pause after climbing ½ flight of stairs. No cough or wheezing.

  • Cardiovascular: She used to have occasional palpitations before but has had none for the last 2 mo. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea.

  • Gastrointestinal: The patient’s bowel movements have decreased from daily to once every 3 to 4 days when using laxatives. She does not have any abdominal pain or vomiting. Her appetite is decreased.

  • Genitourinary: Noncontributory

  • Musculoskeletal: Her ankles and lower legs are more swollen than they used to be. She reports fatigue and leg weakness when climbing stairs or getting up from a chair.

  • Neurologic: She has become slower at performing daily activities, and extra effort is required. Her daughter has noticed that her mother has trouble remembering recent events, such as whether she has taken her medications. She denies having focal weakness or sensory abnormalities, tremor, or visual symptoms.

  • Psychiatric: Her mood is depressed and she often stays in bed, not going out of the house for many days.