Chronic lethargy in a 68 yo woman

Physical Examination

  • General appearance: The patient is wearing several layers of clothing including a wool sweater despite it being 89° F outside. She has a dull facial expression, and she looks pale and tired.

  • Vital signs:
  • Temperature: 35.8° C
  • Pulse: 56 beats/min, irregular
  • BP: 120/90 mm Hg
  • Respirations: 16/min

  • Skin: Skin is cool and dry, no cyanosis or rash. Hair is coarse and dry with noticeable loss of hair from the eyebrows.

  • HEENT: Periorbital edema. Thyroid gland is slightly enlarged bilaterally, firm, and nontender. There is no cervical lymphadenopathy.

  • Pulmonary: Good air entry and exit with a few bibasilar fine end-inspiratory crackles and no wheeze.

  • Cardiovascular: Irregularly irregular heart rate of 56 beats/min, no murmurs, rubs or gallops. Jugular venous pulse visible but not elevated. There is 2+ edema of both lower extremities. Dorsalis pedis pulses are difficult to palpate due to leg edema.

  • Gastrointestinal: Previous appendectomy scar is visible. Abdomen is soft; there is a mild discomfort in the left iliac fossa with normal bowel sounds. Hard, brown, stool is present in the rectum on the rectal examination. Stool is negative for occult blood.

  • Genitourinary: Unremarkable

  • Musculoskeletal: A left wrist scar is present from surgical decompression of carpal tunnel syndrome. Tinel’s sign is positive on the right side.

  • Neurologic: Patient ’s movements and speech are slow but clear, no tremor. Cranial nerves II-XII intact. There is proximal weakness (4+/5) of both lower extremities, otherwise strength and muscle tone are normal and symmetrical; deep tendon reflexes are decreased generally with a prolonged relaxation phase. Plantar reflexes are down-going bilaterally.

  • Mental status: Patient reports a decreased mood but no suicidal thoughts.