CASE 21: TIREDNESS
History
A 55-year-old man presents to his general practitioner (GP), complaining of lack of energy.
He has become increasingly tired over the past 18 months. He works as a solicitor and
describes episodes where he has fallen asleep in his office. He is unable to stay awake after
9.30 pm, and sleeps through until 7.30 am. He finds it difficult to concentrate at work, and
has stopped playing his weekly game of tennis. He had an episode of depression 10 years
ago related to the break-up of his first marriage. He has no current personal problems. He
has had no other major illnesses. His brother developed type 1 diabetes mellitus at the age
of 13. On direct questioning, he has noticed that he has become more constipated but denies
any abdominal pain or rectal bleeding. He has put on 8 kg in weight over the past year.
Examination
On examination he is overweight. His facial skin is dry and scaly. His pulse is 56/min, regu-
lar and blood pressure 146/88 mmHg. Examination of his cardiovascular, respiratory and
abdominal systems is unremarkable. Neurological examination was not performed.
NormalHaemoglobin 10.3 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 92 fL 80–99 fL
White cell count 4.3% 109 /L 3.9–10.6% 109 /L
Platelets 154 % 109 /L 150–440% 109 /L
Sodium 140 mmol/L 135–145 mmol/L
Potassium 4.4 mmol/L 3.5–5.0 mmol/L
Urea 6.4 mmol/L 2.5–6.7 mmol
Creatinine 125 &mol/L 70–120&mol/L
Glucose 4.7 mmol/L 4.0–6.0 mmol/L
Calcium 2.48 mmol/L 2.12–2.65 mmol/L
Phosphate 1.20 mmol/L 0.8–1.45 mmol/L
Cholesterol 6.4 mmol/L 3.9–6.0 mmol/L
Triglycerides 1.4 mmol/L 0.55–1.90 mmol/LUrinalysis: nothing abnormal detected (NAD)INVESTIGATIONS
Questions
- What is the likely diagnosis?
- How would you further examine, investigate and manage this patient?