Differential Diagnosis

The patient's presentation is complex, with multiple factors contributing to their symptoms. The following differential diagnoses are organized into categories based on their likelihood and potential impact.

• Single Most Likely Diagnosis

  • Polycystic Ovary Syndrome (PCOS) with associated metabolic and psychological comorbidities: The patient's hormonal profile (high AMH, slightly high testosterone, and normal 17-OHP) suggests PCOS, which is often associated with insulin resistance, dyslipidemia, and mood disorders. The improvement in HbA1c with Tirzepatide, a medication used for type 2 diabetes and obesity, further supports this diagnosis. The patient's cognitive symptoms, mood disturbances, and hormonal imbalances can be linked to PCOS and its associated metabolic and psychological comorbidities.

• Other Likely Diagnoses

  • Vitamin D deficiency disorder: The patient's severely low vitamin D level (4.84 ng/mL) can contribute to fatigue, mood disturbances, and possibly cognitive symptoms. Addressing this deficiency is crucial for overall health.
  • Depression and anxiety disorder: The patient's DASS21 scores indicate significant depression, anxiety, and stress, which are major contributing factors to their cognitive symptoms. These conditions require separate management.
  • Chronic stress-related disorder: The patient's stress levels, as indicated by their DASS21 scores and the presence of subcortical white matter hyperintensities on MRI, suggest a chronic stress-related condition that may be exacerbating their symptoms.

• Do Not Miss Diagnoses

  • Hypothyroidism: Although the patient's current thyroid function tests (TSH, FT4, FT3) are within normal limits, thyroid disorders can sometimes present with subtle or atypical symptoms. Given the patient's complex presentation, ensuring euthyroidism is crucial.
  • Pituitary or adrenal insufficiency: The patient's hormonal profile and history of weight loss and exercise could potentially mask or contribute to hormonal imbalances. Although less likely, these conditions are critical not to miss due to their potential severity.
  • Migraine or other headache disorders: The patient's MRI showing subcortical white matter hyperintensities could be related to migraine or other headache disorders, especially if the patient experiences headaches. This diagnosis is important for managing symptoms and preventing further complications.

• Rare Diagnoses

  • Adrenal tumors or hyperplasia: The patient's slightly high testosterone and upper-normal DHEAS levels could, in rare cases, indicate adrenal pathology. However, this would be an uncommon cause of their symptoms.
  • Pituitary adenoma or other sellar/suprasellar lesions: Although the patient's hormonal profile does not strongly suggest a pituitary adenoma, rare cases can present with non-specific symptoms. The presence of any mass in the sellar/suprasellar region could explain some of the patient's symptoms, including hormonal imbalances and cognitive changes.
  • Neurodegenerative diseases (e.g., early-onset dementia): The patient's mild cognitive impairment, as indicated by the MoCA score, could rarely be an early sign of a neurodegenerative disease. However, given the patient's age and the presence of other explanatory factors (depression, stress, vitamin D deficiency), this is less likely.