Question 1.
A 21-year-old man comes to the office because he has been feeling very stressed lately. He recently moved from a small town in Iran to Vancouver, Canada to seek out a career as an actor. During the first four months, he becomes increasingly despondent and calls home frequently, telling friends and family about the culture shock. His main comfort is a local hookah bar, but following a city-wide ban on hookah bars and sales for public health reasons he begins to feel more depressed. Medical history reveals that he has lost 10lbs in the past 4 months, which the patient attributes to decreased appetite. He also says that he has begun sleeping less. Which of the following is the most likely diagnosis?
Adjustment disorder with depressive features
Major takeaway
Adjustment disorder is characterized by emotional and/or behavioral symptoms as a reaction to a stressful event within 3 months and rarely lasting longer than 6 months.
Main explanation
A person with adjustment disorder develops emotional and/or behavioral symptoms as a reaction to a stressful event. These symptoms generally begin within three months of the event and rarely last for longer than six months after the event or situation. In an adjustment disorder, the reaction to the stressor is greater than what is typical or expected for the situation or event. In addition, the symptoms may cause problems with a person’s ability to function; for example, the person may be unable to sleep, work, or study. Although the vignette suggests some elements of depression, adjustment disorder is the better answer since the depressed mood has occurred in response to a specific event.
Major depressive disorder
Major depressive disorder is a condition that is diagnosed by recognizing that patients have at least 5 of the 9 SIG-E-CAPS + depressed mood for 2 weeks or longer.
Reactive attachment disorder
Reactive attachment disorder is a condition in infants that is usually related to long-term infant deprivation and is characterized by the baby being unresponsive or withdrawn to affection or comfort.
Separation anxiety disorder
Separation anxiety disorder is a condition usually recognized in children before the age of 10 that typically results from extreme fear of being away from home or a parent. It can be treated with cognitive behavioral therapy.
Substance use disorder
Substance use disorder may be diagnosed when a patient has increased tolerance to and continual use of drugs or alcohol despite said use’s interference with important duties at work or home.
Question 2.
A 24-year-old man comes to the clinic because a protruding forehead and mandible as well as hypertrichosis. The patient’s mother is concerned because he has not stopped growing and is over a foot taller than everyone else in his family. Blood tests reveal an elevated serum IGF-1 as well as a failure to suppress serum growth hormone following an oral glucose tolerance test. The physician recommends magnetic resonance imaging (MRI) of the brain, which would most likely reveal a lesion in which of the following bony structures?
Cribriform plate
The cribriform plate of the ethmoid bone supports the olfactory bulb and is perforated by the foramina for the passage of the olfactory nerves. A lesion in this region would likely affect the olfactory nerves and possibly the nasociliary nerves.
Greater wing of the sphenoid bone
The greater wing of the sphenoid bone consists of numerous foramina–including foramen ovale and foramen spinosum–as well as the posterior aspect of the orbit. A lesion in this region would likely affect the trigeminal nerve, lesser petrosal nerve, and/or venous drainage of the skull.
Internal auditory meatus
The internal auditory meatus is a canal within the petrous part of the temporal bone that provides a passageway for the vestibulocochlear nerve, facial nerve, and labyrinthine artery. A lesion in this region would likely affect hearing, balance, and the muscles of facial expression.
Pterygoid canal
The pterygoid canal runs through the medial pterygoid plate of the sphenoid bone to the back wall of the pterygopalatine fossaand transmits the Vidian nerve. A region in this region would likely affect innervation of the lacrimal glands as well as blood vessels and mucous glands in the head.
Sella turcica
Major takeaway
Acromegaly is a rare syndrome caused by the production of growth hormone by the anterior pituitary gland after closure of the epiphyseal plates. It is often caused by a pituitary adenoma, which would be located within the sella turcica of the sphenoid bone.
Main explanation
This patient most likely has acromegaly, a rare syndrome caused by the production of growth hormone by the anterior pituitary gland after closure of the epiphyseal plates. The source of this excess growth hormone is often a pituitary adenoma comprised of somatotrophs. The anterior pituitary gland is encased within the hypophyseal fossa, which is the deepest part of the sella turcica of the sphenoid bone. Thus, magnetic resonance imaging (MRI) of this patient would likely reveal a lesion in this region.
Acromegaly most commonly affects middle-aged adults and can result in severe disfigurement and fatal complications if not treated. Management can either be pharmacological–including the administration of somatostatin–or surgical. Options for surgery include endonasal transsphenoidal surgery, which goes through the nasal cavity wall, or transsphenoidal surgery, which enters through the gum beneath the upper lip
Question 3.
A 30-year-old woman, G0P0 comes to the office because of difficulty becoming pregnant. She states that has been having regular, unprotected intercourse with her partner for two years without any pregnancies. Her periods are regular, occurring every 28 days, and are associated with heavy bleeding and severe cramping. She also reports intermittent pelvic pain over the last 5 years, and pain with intercourse. Pelvic examination shows adnexal tenderness. Which of the following is the most likely diagnosis?
Mayer-Rokitansky-Kuster-Hauser syndrome
Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) or Mullerian Agenesis is a congenital disorder of mullerian duct development in which the uterus and fallopian tubes fail to form, and there is a variable degree of vaginal hypoplasia. Of course, women with MRKH do not menstruate.
Polycystic ovarian syndrome
PCOS is a syndrome characterized by oligo- or amenorrhoea and symptoms of androgen excess. It is frequently associated with infertility secondary to anovulation.
Endometriosis
Major takeaway
Endometriosis is a common cause of infertility and is characterized by the presence of ectopic endometrial tissue outside of the uterus. Common symptoms include cyclical pelvic pain, dysmenorrhea, dyspareunia, and abnormal uterine bleeding.
Main explanation
Endometriosis is the presence of endometrial tissue outside of the uterine cavity. The most common symptoms of endometriosis are cyclical pelvic pain, dysmenorrhea, dyspareunia (pain during sexual intercourse), abnormal bleeding, and infertility. Endometriosis can interfere with tubal mobility, cause tubal obstruction, and result in tubal or ovarian adhesions that contribute to infertility.
The most common locations of ectopic endometrial tissue are on the ovaries, the uterine tubes, and in the Pouch of Douglas.
The physical examination is often unremarkable, or may be positive for pelvic, adnexal, or abdominal tenderness. Definitive diagnosis can be made with laparoscopy which allows for visualisation and biopsy of pelvic lesions.
Initial approach to treatment consists of conservative surgery with removal of pelvic lesions. Induction of ovulation and intrauterine insemination may be recommended if the couple continues to have difficulty conceiving following surgical intervention.
Padma Lakshmi, television host and model most known for hosting “Top Chef”, has openly struggled with becoming pregnant due to her having endometriosis.
Asherman syndrome
Asherman syndrome is characterized by scarring and fibrosis of the endometrial cavity with formation of intrauterine adhesions. It is commonly associated with infertility. Asherman’s syndrome typically occurs following a prior intrauterine procedure such as dilation and curettage, followed by amenorrhea or hypomenorrhea due to the obstruction of menstrual flow.
Premature ovarian failure
Premature ovarian failure is characterized by infertility, menstrual irregularities, and other symptoms of menopause, such as hot flashes, in a woman under the age of 40.
Question 4.
A female newborn is delivered at 33 weeks’ gestation, has expiratory grunting and blue extremities. Her temperature is 39.2°C (102.56°F), pulse is 225/min, and respirations are 65/min. Physical examination shows nasal flaring and chest wallretractions. Apgar scores are 5 at 1 minute and 5 at 5 minutes. Which of the following is the most appropriate next step in management?
Hepatitis B vaccine
Hepatitis B vaccine is a vaccine that prevents hepatitis B. The first dose is recommended within 24 hours of birth with either two or three more doses given after that. This includes those with poor immune function such as from HIV/AIDS and those born premature.
Phototherapy
Phototherapy consists of exposure to daylight or to specific wave lengths of light using polychromatic polarised light, lasers, light-emitting diodes, fluorescent lamps, dichroic lamps or very bright, full-spectrum light. One common use is for the treatment of skin disorders, chiefly psoriasis, acne vulgaris, eczema, and neonatal jaundice.
Surfactant
Major takeaway
Exogenous surfactant (e.g. Survanta), or perfluorocarbon aerosol, are used for the treatment ofinfant respiratory distress syndrome (IRDS), which appears in premature infants and is caused by developmental insufficiency of surfactant production and structural lung immaturity. IRDS is characterized by hyperpnea, tachycardia, chest wall retractions, expiratory grunting, nasal flaring, and cyanosis.
Main explanation
Infant respiratory distress syndrome (IRDS) appears in premature infants and is caused by developmental insufficiency of surfactant production and structural immaturity in the lungs. It results from a neonatal infection or a genetic disorder with the production of surfactantassociated proteins. IRDS affects 1% of newborns, is the leading cause of death in preterm infants, and is characterized by hyperpnea, tachycardia, chest wall retractions, expiratory grunting, nasal flaring, and cyanosis. Histopathology shows layers of hyalinemembrane, collapsed alveoli, vascular congestion, over-distention of airways, and damaged lining cells. The diagnosis is made by the clinical picture and chest X-ray, which shows a “bell-shaped chest”, absence of the thymus, a small, uniform infiltrate (“diffuse airspace and interstitial opacities”), air-bronchograms, and a “white-out” appearance of the heart. Diagnose is also made by lung maturity studies with microbubble tests, lamellar body counts (LBC), and measurements of lecithin-sphingomyelin ratio (L/S, through amniotic fluid analysis) with chemometrics. Treatment is with oxygen given with small amounts of continuous positive airway pressure (“CPAP”), intravenous fluids, an endotracheal tube, and intermittent breaths given by a mechanical device. An exogenous surfactant is given (most commonly used is Survanta) or an aerosol of a perfluorocarbon.
Vitamin K
As a result of the occurrences of vitamin K deficiency bleeding, the Committee on Nutrition of the American Academy of Pediatricshas recommended that from 0.5 to 1.0 mg of vitamin K1 needs to be administered to all newborns shortly after birth.
Influenza vaccine
Influenza vaccines are vaccines that protect against influenza. A new version of the vaccine is developed twice a year as the influenza virus rapidly changes. Is recommended in pregnant women, children between six months and five years of age, those with other health problems, native americans, and those who work in healthcare.
Question 5.
An 85-year-old man is brought to your office by his daughter because of an inability to “throw anything away” for 2 years. She states that their house is overrun with items and that insects have begun to make homes in them. The father replies that he can get rid of things but only if he is able to sell them or find a way to trade them for fair value. He explains that he grew up during the great depression and that his father was a banker who lost everything. The father always told the patient to invest in physical goods, as “that is the only thing that retains its value in a depression.” Which of the following is the most likely diagnosis?
Hoarding disorder
Major takeaway
Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardles of their actual value. The affected individual perceives a need to save these items and feels distress at the notion of discarding them.
Main explanation
This patient may be suffering from hoarding disorder, a DSM V diagnosis associated with “persistent difficulty discarding or parting with possessions, regardless of their actual value.” The affected individual perceives a need to save these items and feels distress at the notion of discarding them. Hoarding behaviors lead to serious dysfunction or impairment in key areas of their life (i.e. insect infestations and possibly secondary illnesses in the home, family conflict). Hoarding disorder represents a subset of the obsessive compulsive disorders.
These disorders are characterized by the presence of obsessions, compulsions, or both. Obsessions are recurrent/persistent thoughts and/or urges that cause the patient distress and anxiety. Compulsions are repetitive behaviors or thoughts that occur in response to the obsession. These behaviors/thoughts are meant to reduce the distress caused by the obsession. An example is a fear of intrusion that leads a patient to check the front door 30 times per day, despite the fact that this impacts their social and working life.
Major depressive disorder
A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks. This patient has not features suggestive of depression, but these could include depressed mood, anhedonia, and reduced energy.
Obsessive compulsive disorder
Obsessive compulsive disorder (OCD) is characterized by obsessions, compulsions, or both. Hoarding can be a compulsion, but the current DSM lists hoarding disorder as both a mental disability in its own right, as well as a possible symptom for OCD.
Schizophrenia
To be diagnosed with schizophrenia, a patient must be suffering from delusions, hallucinations, or disorganized speech. This patient has none of those symptoms. Patients with schizophrenia must also a second symptom such as negative symptoms, or severely disorganized or catatonic behaviour.
Obsessive compulsive personality disorder
Patients with obsessive compulsive personality disorder (OCPD) are in harmony with their personality. OCPD is a life long pattern with the person strictly following their own rules, without an impact on their social or working lives.
Question 6.
A 25-year-old medical student comes to the psychiatric clinic because of difficulties working in groups over the past year. While in the waiting room, he demands to be seen by the chair of psychiatry himself because he has “a reputation to uphold.” During the visit, he explains that he refuses to cooperate on any group projects with other students because he insists that he can do the work better himself. He further notes that he wants to specialize in experimental neurosurgery and can’t have other students dragging down his grades. He reports that he often enters professors offices or the faculty lounge uninvited to share personal anecdotes and “fascinating” stories from his research. He also states that he has no issues with exploiting his classmates for his own gain because medical school is “inherently competitive.” Which of the following disorders does this patient most likely have?
Histrionic personality disorder
Histrionic personality disorder is a cluster B disorder. These patients are emotional and dramatic. They wear provocative clothing in an attempt to gain attention. They have a difficult time keeping long term relationships. Regression is a common defense mechanism utilized by these patients.
Borderline personality disorder
Borderline personality disorder is a cluster B disorder. These patients are impulsive, emotionally unstable, and suicidal. They fear abandonment and as a result often times have unstable relationships. They use splitting as their defense mechanism and will often times commit self-mutilation.
Narcissistic personality disorder
Major takeaway
Narcissistic personality disorder is a cluster B disorder. These patients have an inflated senseof self, sense of entitlement, and lack of regard for others.
Main explanation
Narcissistic personality disorder is a cluster B disorder. These patients have an inflated senseof self, sense of entitlement, and lack of regard for others. They have a need for admiration and are willing to sacrifice others for their personal gain. They are also excessively sensitive to criticism and actually have a low self-esteem. These patients will insist upon a different set of rules for themselves and have unrealistic notions of their attractiveness. For instance, these patients will refuse to let a resident treat them and insist on seeing the chair of a department. Narcissistic personality disorder affects less than 1% of the general population. While similar to antisocial personality disorder, these patients will display an exaggerated sense of self-worth whereas patients with antisocial personality disorder are primarily motivated by material or personal gain.
Remember that personality disorders are egosyntonic disorders, meaning that these individuals do not sense that their perception of the world is wrong. This makes treatment especially difficult. Psychotherapy has been shown to be helpful. Antidepressants and lithiummay be utilized to help control any mood swings or depressive episodes the patient may experience.
Antisocial personality disorder
Antisocial personality disorder is a cluster B disorder. These patients have a prior history of conduct disorder as a teenager. They lack empathy, compassion, and remorse. These patients will not hesitate to exploit others for their own self gain. They are very sociable and may come off as charming.
Paranoid personality disorder
Paranoid personality disorder is a cluster A personality disorder characterized by an intense mistrust and suspicion of others. These patients are quick to blame others for their misfortune and are often angry and jealous. This disorder is more common in males compared to females.
Question 7.
A 13-year-old boy has been suspended 5 times this year for arguing with teachers. He has presented a pattern of negativism and hostility that has lasted for about 8 months. When asked about the suspensions, he admits that he loses his temper easily and often blames the principal for not being fair to him. He usually finds an argument before finishing his homework. At home, he goes out of his way to annoy his siblings. He gets furious if his legal guardian finds out about it and confiscates his smartphone. Which of the following is a characteristic behavior of this disorder?
Violating the rights of others
Conduct disorder is characterized by repetitive and persistent pattern of behavior occurs in which the basic rights of others or major age-appropriate societal norms or rules are violated.
Hostile and disobedient behavior towards authority
Major takeaway
Oppositional defiant disorder is characterized by a pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness lasting at least 6 months. Presentation includes recurrent loss of temper, arguing, refusing to comply with rules, deliberately annoying others, blaming others for behavior, and resentfulness.
Main explanation
The patient in this question most likely has oppositional defiant disorder (ODD). It is a childhood psychiatric diagnosis used to describe children with behavioral problems not due to substance abuse or psychotic disorders. It is characterized by a pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness lasting at least 6 months. The individual tends to get angry, argues with adults, and refuses to comply with adult requests. Symptoms may be present at home and in the community or at school. ODD is often comorbid with attention-deficit hyperactivity disorder (ADHD), and can sometimes lead to the development of conduct disorder. ADHD must first be ruled out in children with ODD, and treatment consists of therapy for the patient and parent management training. Conduct disorder, in comparison, is a repetitive and persistent pattern of behavior occurs in which the basic rights of others or major age-appropriate societal norms or rules are violated. Behaviors used to classify conduct disorder would fall into the 4 main categories of (1) aggression toward people and animals; (2) destruction of property without aggression toward people or animals; (3) deceitfulness, lying, and theft; and (4) serious violations of rules.
Destruction of property and theft
Destruction of property and theft is characteristic of conduct disorder, a childhood psychiatric disorder with repetitive and persistent pattern of maladaptive behavior.
Physical aggression
Physical aggression is characteristic of conduct disorder, a childhood psychiatric disorder with repetitive and persistent pattern of disruptive and disobedient behavior and violation of the basic rights of others.
Killing and/or harming small animals
Killing and/or harming small animals is a characteristic feature of sociopathy and/or psychopathy, as well as people exhibiting antisocial behaviors.
Question 8.
A 2-year-old boy comes to the clinic because of a non-progressive motor function disorder. Collateral history from his mother shows he has problems thinking, learning and communicating with others. Physical examination shows poor coordination, unsteady gait, and hyperreflexia (with increased muscle tone). The patient has several involuntary facial muscle spasms during the consult. Which of the following is the most likely diagnosis?
Febrile seizures
Febrile seizures are a common condition between the ages of 6 months and 6 years. Simple febrile seizures have no increased risk of seizure disorders or neurological damage.
Cerebral palsy
Major takeaway
Spastic diplegia is the most common type of cerebral palsy and patients generally present with hypertonia, hyperreflexia and muscle spasticity.
Main explanation
Cerebral palsy (CP) is a non-progressive condition that is characterized by neuromusculardysfunction. The underlying damage may occur in utero, during delivery or be acquired in early life due to, for example, trauma, encephalitis, or hypoxia.
Though symptoms of CP may become more noticeable as a young child ages, the underlying pathology does not worsen with time. Early signs may include an infant not rolling, sitting, or walking within the expected timeframe.
Spastic diplegia is the most common form of CP and features hypertonia and spasticity which may be seen as increased reflexes, abnormal gait, and involuntary muscle contractions. There is sometimes, but not always, an associated intellectual disability or speech impairment in patients with CP.
Congenital hydrocephalus
Congenital hydrocephalus, where there is increased volume of cerebro-spinal fluid, is usually identified during the first months of life. Signs include a large head, bulging fontanelle, and hypertonia. Feeding difficulties and irritability are common.
Down syndrome
Down syndrome is a genetic disorder caused by a trisomy of chromosome 21. It is characterised by hypotonia, developmental delay, and physical features including a flat nasal bridge, low set ears, single palmar creases, and epicanthic folds.
Arthrogryposis
Arthrogryposis, or arthrogryposis multiplex congenita, refers to the finding of multiple joint contractures at birth. These contractures are non-progressive and the finding may be seen in association with several different conditions, including cerebral palsy.
Question 9.
A 50-year-old man comes to his primary care providers office because of increased cough and dyspnea for the past 3 months. He reports that he began developing a dry and heaving cough and has had increasing shortness of breath and dyspnea upon exercise. He is a carpenter and has a 20 pack year history of smoking. Physical examination shows inspiratory crackles upon auscultation and digital clubbing. A chest radiograph shows peripheral interstitial opacities. Which of the following is the next best step in diagnosis?
Follow-up chest radiograph in three months
A follow-up chest radiograph is a good option in following patients with lung nodules and lesions over time. This is done to ensure that the lesions don’t change in shape or size and to rule out lung carcinoma. In patients with idiopathic pulmonary fibrosis, chest radiographs are not diagnostic.
High resolution computed tomography
Major takeaway
Idiopathic pulmonary fibrosis is a condition characterized by progressive fibrosis of the lung tissue leading to shortness of breath, dyspnea, and worsening pulmonary function testing. Diagnosis can be made with a high resolution computed tomography (HRCT) scan. If HRCT is unclear, then a biopsy should be done.
Main explanation
Idiopathic pulmonary fibrosis (IPF) is a chronic interstitual lung disease characterized by progressive fibrosis of the lung tissue leading to shortness of breath, dyspnea, and worsening pulmonary function testing. IPF is a restrictive lung disease that occurs in the elderly population (between 50-70 years of age). A big risk factor for IPF is smoking. Other risk factors include environmental exposures such as wood and coal dust. Physical examination will show bibasilar crackles upon pulmonary auscultation and clubbing of the digits secondary to oxygen deficiency. Diagnosis of IPF can be difficult and requires the exclusion of all other causes of interstitial lung disease. The first step in patients suspected of IPF should be a high-resolution computed tomography (HRCT) scan. A HRCT scan should show the presence of usual interstitial pneumonia pattern and in some cases are diagnostic for the condition. In instances in which the imaging is unclear, a lung biopsy should be done to confirm the diagnosis. IPF is ultimately fatal and treatment is targeted at slowing the progression of the disease and alleviating symptoms. Medications currently being used for treatment include pirfenidone, N-acetylcysteine in combination with prednisone and azathiprine, and Nintedanib.
Initiation of chemotherapy
Chemotherapy is the treatment of choice in certain lung cancers such as small cell carcinoma. Small cell cancer is aggressive and usually has metastasized at time of presentation. Small cell cancers show up as nodules within the central area of the lung.
Surgical biopsy of the lung
A surgical biopsy may be useful in the diagnosis of idiopathic pulmonary fibrosis (IPF) in instances where a high resolution computed tomography (HRCT) is unclear. However, in certain situations, a HRCT is sufficient enough for the diagnosis of IPF. A HRCT should be done first before a biopsy is considered.
Surgical resection of the lung
Surgical resection of the lung is done in certain lung cancers such as large cell lung carcinoma. Large cell cancers carry a poor prognosis and a surgical resection should be done rather than chemotherapy.
Question 10.
A 30-year-old man comes to the clinic because of fatigue and sleepiness throughout the day. His past medical, family, and social histories are noncontributory. His wife says he snores very loudly while sleeping and she has recently noticed that he will stop breathing momentarily, multiple times throughout the night. Pulse oximetry shows a blood oxygen saturation of 90%. He has a BMI of 33kg/m2, having gained 5.4-kg (12-lb) over the past year without any significant lifestyle or dietary changes. You advise the patient to lose weight and see a relevant specialist. Which is the most likely cause of this patient’s condition?
Anaemia
Anaemia is an important cause of fatigue but the lack of a significant medical history in addition to his sleep and weight-related findings are suggestive of another cause.
Obstructive sleep apnea
Major takeaway
Obstructive sleep apnea is characterized by intermittent upper airway obstruction during sleep. It is an important cause of fatigue to recognize and treat as it can have serious long term complications.
Main explanation
This patient’s fatigue and drowsiness are most likely due to obstructive sleep apnea affecting his regular night sleep. Obstructive sleep apnea describes a reversible intermittent obstruction of the upper airway at night. During sleep, the body’s muscle tone decreases; because the tongue and pharynx are composed of soft tissue, they collapse and reduce patency of the airway. This can cause snoring as they vibrate with the turbulent airflow. If the airwayobstructs completely, the patient becomes apneic. Carbon dioxide accumulates in the patient’s blood until it arouses the patient to awaken or to a shallower level of sleep. Muscle tone is returned at this point and the patient is able to recommence breathing. Patients will run through this cycle many times a night, preventing them from sustaining deeper levels of sleep.
Recent unintentional weight gain and excessive daytime sleepiness are two hallmark signs of obstructive sleep apnea. Obesity is a leading risk factor especially for men, who tend to store more fat in the neck. Formal diagnosis may require an overnight sleep study. Obstructive sleep apnea can have serious complications due to decreased oxygen flow to organs like the heart and brain.
Orthopnoea
Orthopnoea is shortness of breath that occurs while lying flat and is alleviated by sleeping propped upward. It is the opposite of platypnea, and is commonly seen in patients with late congestive heart failure.
Platypnoea
Platypnoea is shortness of breath that worsens when sitting or standing, and alleviates by lying flat. In contrast, this patient’s sleep interruptions suggest lying down may cause rather than relieve his other symptoms.
Type 2 diabetes mellitus
Obesity is a risk factor in developing type 2 diabetes mellitus. While fatigue can mark the onset of diabetes, the rest of this presentation – notably hypoxemia and no dietary changes – suggest a different underlying condition
