NR-511 Differential Diagnosis & Primary Care Practicum

Week 6 Case Study Discussion Part 1

A 56-year-old Caucasian female presents to the office today with complaints of fatigue.

Upon further questioning you discover the following subjective information regarding the

chief complaint.

History of Present Illness

Onset "about 2-3 months"

Location Generalized

Duration Constant

Characteristics Progressively worsening since onset,

feels tired all of the time, sleeps 8hrs per

night but does not feel well rested. "No

energy to do anything I normally can do"

Aggravating factors Exertion

Relieving factors None identified

Treatments None

Severity Denies pain; missed 1 day of work 2

weeks ago because "couldn't get out of

bed"

Review of Systems (ROS)

Constitutional Denies fever, chills, or recent illnesses.

+5lb. weight gain since last visit 6 months

ago.

Eyes No visual changes or diploplia

ENT Denies ear pain, coryza, rhinorrhea, or

ST. Had tonsillectomy as child Denies

snoring or history of sleep apnea.

Neck Denies lymph node tenderness or

swelling

Chest Denies cough, SOB, DOE or wheezing

Heart Denies chest pain

Abdomen Denies N/V/D. + Constipation

Endocrine Denies polyuria, polydipsia. + cold

intolerance. Menopause status x 5 yrs.

Skin No changes in skin, hair or nails