Mr. Ahmed is a 72-year-old retired accountant who lives with

his daughter. Over the past 6–8 months, she has noticed a gradual but

progressive decline in his energy level and daily functioning. Previously

independent, he now spends most of the day seated, naps frequently, and has

reduced interest in social activities he once enjoyed. He denies chest pain or

dyspnea but reports persistent fatigue and a ‘heavy’ feeling in his limbs.

He frequently complains of feeling cold, even when other

family members are comfortable. He has begun wearing layered clothing indoors

and uses extra blankets at night. His daughter also reports that his speech has

become slower and somewhat slurred, with longer pauses between words. He

appears less expressive facially and occasionally seems forgetful, though he

denies confusion.

Past Medical History

• Myocardial

  infarction 8 months ago, treated with percutaneous coronary intervention

• Type 2

  Diabetes Mellitus (15-year history)

• Epilepsy

  (well-controlled, no seizures in 5 years)

• Hypertension
• Hyperlipidemia

Medications

• Aspirin

  81 mg daily

• Atorvastatin

  40 mg nightly

• Metoprolol

  succinate 50 mg daily

• Lisinopril

  10 mg daily

• Metformin

  1000 mg twice daily

• Phenytoin

  300 mg daily

No recent medication changes have been reported. Adherence

is described as consistent.

 Physical Examination

• General:

  Appears fatigued, slow to respond but oriented. Speech is slowed with mild

  dysarthria.

• Vital

  Signs:

• Blood

  Pressure: 128/74 mmHg

• Heart

  Rate: 54 bpm

• Respiratory

  Rate: 14/min

• Temperature:

  36.1°C

• Skin:

  Dry, coarse, cool to touch; mild non-pitting edema of hands.

• Face:

  Periorbital puffiness; thinning of the lateral eyebrows.

• Neck:

  Thyroid gland not visibly enlarged; no nodules palpated.

• Cardiovascular:

  Bradycardic but regular rhythm; no murmurs.

• Neurologic:

  Delayed relaxation phase of deep tendon reflexes; mild proximal muscle

  weakness; slowed mentation but intact cognition.

• Extremities:

  No tremor; mild non-pitting edema.

Laboratory Findings

• TSH:

  12 mIU/L (0.45–4.5 mIU/L)

• Free

  T4:

  0.3 ng/dL (0.8–1.7 ng/dL)

Questions

1. 

Provide a definitive diagnosis for Mr.

Ahmed’s thyroid status, classifying the specific type of disorder based on the

laboratory findings. (2 marks)

2.  

Identify three signs or symptoms from his

presentation that support your finding. (3 marks)

3. Formulate a specific initial therapy and dosing

regimen for Mr. Ahmed (medication name, dose and frequency). Justify your dose

selection. (5 marks)

4. Analyze the potential pharmacological

interactions between Mr. Ahmed's existing medications and the initiated therapy.

What adjustments might be necessary? (2 marks)