Presenting Complaints

The patient presents with concerns about progressive hair loss over the past 2-3 years.

History of Presenting Complaint

The patient first noticed gradual thinning of his hair, particularly at the temples and the crown of his head, around 2-3 years ago. The hair loss has been slowly progressive since then, with no sudden or patchy hair loss. He does not recall any preceding illness, high fever, or significant stress that may have triggered the hair loss. The patient denies any associated symptoms like itching, scaling, or redness of the scalp.

Significant Positives & Negatives For Differentials

Androgenetic Alopecia (Male Pattern Baldness)

Positives:

• Gradual, diffuse thinning of hair, particularly at the temples and crown
• Positive family history of similar pattern of hair loss
• No associated symptoms like itching, scaling, or sudden hair loss

Negatives:

• Lack of sudden or patchy hair loss
• No preceding illness, high fever, or significant stress that may have triggered the hair loss

Telogen Effluvium

Positives:

• Diffuse hair shedding
• Potential triggering factors like stress, illness, or medication changes

Negatives:

• Lack of sudden or patchy hair loss
• No associated symptoms like itching or scaling
• No clear triggering event reported by the patient

Alopecia Areata

Positives:

• Patchy, non-scarring hair loss
• Potential autoimmune etiology

Negatives:

• Lack of sudden or patchy hair loss
• No associated symptoms like itching or scaling
• No history of other autoimmune conditions

Traction Alopecia

Positives:

• Hair loss due to excessive pulling or tension on the hair

Negatives:

• Lack of sudden or patchy hair loss
• No history of hairstyles or activities that could cause traction on the hair
• No associated symptoms like itching or scaling

Past Medical History

The patient has no significant past medical history. He does not have any chronic medical conditions and takes no regular medications.

Drug/Medication History

The patient takes no regular medications and denies using any over-the-counter or herbal supplements.

Social History

The patient is married and works as an accountant. He does not smoke or drink alcohol excessively. There are no major stressors in his personal or professional life.

Family History

The patient's father also experienced gradual hair loss starting in his 40s, which progressed to significant baldness over time. The patient is not aware of any other family members with similar hair loss issues.

Systems Review

Apart from the hair loss, the review of other body systems is unremarkable. The patient denies any changes in weight, appetite, energy levels, or other systemic symptoms.

Ideas, Concerns & Expectations

The patient is concerned about the progressive nature of his hair loss and is worried that he may eventually become bald. He is interested in understanding the cause of his hair loss and exploring any available treatment options.

Case Presentation

Based on the patient's history and lack of associated symptoms, the most likely initial diagnosis is androgenetic alopecia, or male pattern baldness. The gradual, diffuse thinning of hair, particularly at the temples and crown, is characteristic of this condition. The positive family history also supports this diagnosis.

Other potential differential diagnoses to consider include telogen effluvium, alopecia areata, and traction alopecia. However, the lack of associated symptoms like itching, scaling, or sudden hair loss makes these less likely in this patient's case.