🌧Mock Patient Script: Depression – Standard

Practice clinical English and diagnostic reasoning with two nuanced cases of low mood and fatigue. Not everything that looks like depression is purely psychiatric.

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Case I

🚪 Doorway Information

• Age: 34
• Gender: Female
• Chief Complaint: “I’ve been feeling low and tired all the time.”
• Vital Signs: BP 108/72, HR 62, Temp 36.2°C, SpO2 98%

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📋 Structured History

Opening

“I’m just not myself anymore. It’s like both my mind and body are exhausted.”

Onset & Course

“It started around three months ago. I didn’t think much at first, but it’s been gradually worsening.”

Fatigue & Mood

“I feel tired all the time. I cry easily, but it’s more about feeling empty.”

Appetite & Weight

“I’ve lost weight—about 3 kg. I just don’t enjoy eating.”

Sleep

“I have trouble falling asleep and wake up early. I never feel refreshed.”

Other symptoms

“Sometimes I feel cold and my skin’s been dry.”

Stress History

“There’s been a lot going on at work. I also had a miscarriage last year, and I don’t think I’ve fully recovered emotionally.”

Medications:

None

PMH:

Miscarriage 1 year ago

FH:

Mother has hypothyroidism

SH:

Non-smoker, occasional alcohol

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🩺 Physical Exam Findings

• General: Appears tired, slow speech
• Vitals: HR 62, BP 108/72, Temp 36.2°C
• Skin: Pale, dry
• Neck: No goiter or lymphadenopathy
• Cardiac: Regular rate and rhythm
• Neurologic: Slightly delayed reflexes, no focal signs
• Abdomen: Soft, non-tender

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🧠 Differential Diagnosis

1. Hypothyroidism
   • ✔️ Supporting: Fatigue, weight loss, cold intolerance, dry skin, family history
   • ❌ Against: No goiter, not bradycardic
2. Major Depressive Disorder
   • ✔️ Supporting: Low mood, early waking, appetite loss, anhedonia
   • ❌ Against: Physical signs suggest endocrine contribution
3. Iron-deficiency anemia
   • ✔️ Supporting: Fatigue, recent miscarriage
   • ❌ Against: No mention of pallor or tachycardia

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💬 Clinical Reflection

It’s easy to label patients with fatigue and low mood as having “just depression.” But this case highlights how physical symptoms—especially signs like dry skin, family history, and cold intolerance—should prompt a thyroid workup.

💡 Clinical Pearls

• Always consider endocrine causes for fatigue—especially hypothyroidism.
• Low mood + physical symptoms ≠ purely psychiatric.
• Family history is crucial.

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Case II

🚪 Doorway Information

• Age: 29
• Gender: Female
• Chief Complaint: “I thought I was just feeling depressed, but it’s like my body is giving up.”
• Vital Signs: BP 108/72 → 88/56 on standing, HR 64, Temp 36.2°C

📋 Structured History

Opening

“I thought I was just feeling depressed, but it’s like my body is giving up.”

Onset & Course

“It started about a month ago, suddenly. I used to be active, but now just climbing stairs feels impossible.”

Fatigue & Mood

“It’s more than being tired. My arms and legs feel heavy. I feel gloomy, but mostly just… drained.”

Appetite & Weight

“I have no appetite. I lost around 5 kg. But oddly, I crave salty food.”

Sleep

“I sleep too much, and still wake up exhausted—especially in the mornings.”

Other symptoms

• “Sometimes I get dizzy when I stand up.”
• “My skin’s been dry, and I feel cold even when others don’t.”
• “My period is irregular. Actually, I haven’t had it in three months.”
• “I’ve been craving salty food lately.”

Stress & Past Events

“After my second delivery two years ago, I lost a lot of blood. Since then, I’ve never really felt the same.”

Medications:

None

PMH:

2 pregnancies, no psych history

FH:

Negative for endocrine or mood disorders

SH:

Non-smoker, no alcohol or drugs

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🩺 Physical Exam Findings

• General: Thin, pale, appears fatigued
• Vital Signs: Positive orthostatic drop
• Skin: Cool, dry, no hyperpigmentation
• Cardiovascular: Soft heart sounds
• Neurologic: Slightly delayed reflexes
• Abdomen: Soft, non-tender

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🧠 Differential Diagnosis

1. Secondary Adrenal Insufficiency (Sheehan Syndrome)
   • ✔️ Supporting: Postpartum hemorrhage, amenorrhea, hypotension, fatigue, salt craving
   • ❌ Against: Onset was not immediate postpartum (though consistent with delayed pituitary failure)
2. Major Depressive Disorder
   • ✔️ Supporting: Low mood, fatigue, oversleeping
   • ❌ Against: Prominent physical signs and orthostasis
3. Hypothyroidism
   • ✔️ Supporting: Fatigue, amenorrhea, dry skin
   • ❌ Against: No goiter or bradycardia, salt craving more typical of adrenal

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💬 Clinical Reflection

This case illustrates the importance of taking an obstetric history. A delayed onset of pituitary dysfunction after postpartum hemorrhage—Sheehan syndrome—is a rare but classic cause of fatigue and amenorrhea.

💡 Clinical Pearls

• Salt craving is a red flag for adrenal dysfunction.
• Don’t forget orthostatic vitals in fatigue cases.
• Always ask about delivery complications in women with vague symptoms.

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📚 References

• UpToDate. “Evaluation of fatigue in adults.”
• American Thyroid Association. “Hypothyroidism: Diagnosis and Management.”
• Medscape. “Adrenal Insufficiency and Sheehan Syndrome.”
• DSM-5. “Diagnostic Criteria for Major Depressive Disorder.”
• PHQ-9 Questionnaire Download

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📘 Read: Symptom-Based Approach to Depression
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