Patient Information

Initials: C.P, Age: 31 yo. Race: Hispanic. Sex: female. Insurance: Blue cross blue shield

CC: Fatigue

HPI: C.P presents to the clinic today with reports that over the past three month, she has been

having an increased lack of energy and pleasure in the things she previously enjoyed doing. She

reports that although she has a highly stressful and demanding job as a sales executive in a

multinational company, she has always been able to keep up with the demands. She prides

herself as a high achiever and can sometimes be critical when unable to meet some of the high

standards she set for herself. She states, “lately I have not been as highly achieving as I used to

be on the job” She reports feelings of worthlessness and shame due to this.

C.P reports that not only has she been feeling unusually tired, but she has not been able to find

joy or enjoy any activity. She states, “I don’t feel like doing anything or going anywhere”. She is

not able to concentrate at work and her coworkers have told her that she is often withdrawn and

irritable. She has called in sick a few times lately which is unlike her. She reports that she has

gained quite some weight lately, because on those days that she is home, she eats nonstop, stays

in bed all day watching television and sleeping. Denies any previous treatment or thoughts of

suicide.

PMHx: No major illness

Childhood/previous illnesses: Chicken pox

Chronic illnesses: None

Surgeries: Appendectomy

Hospitalizations: None except for appendectomy

Immunizations: Flu shot

Social History: Patient is single and works as a company executive at a multinational company.

She likes to stay fit by walking, working out in the gym, and eating healthy, although lately she

has found it difficult to go out with friends or work out at the gym. Denies drinking alcohol

beverages and never smoked.

Family History: Father died at the age of 61 from complications of stroke; Mother has bipolar

disorder. Brother has depression.

Allergies: NKDA

Current medications: Daily multivitamin

ROS:

General: Patient denies fever and chills but reports weight gain. Reports pain and stiffness in

knee joint.

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HEENT: Denies headaches, blurry vision, dizziness, ear pain, or nasal discharge.

Integumentary: Denies bruising, or recent changes. Reports mild swelling to right knee.

Lymphatics: Denies enlarged lymph nodes.

Lungs: Denies shortness of breath, cough, or wheezing.

Cardiovascular: Denies chest pain or palpitations

Musculoskeletal: Patient reports pain and stiffness to right knee

PE:

Vital signs: BP 130/78, P 70, Resp 16, Sao2 98%. Height: 5'4" weight: 182 pounds; BMI 31.24,

pain 5/10.

General Appearance: Caucasian female who appears her stated age with antalgic gait. Alert,

oriented, and cooperative.

Skin: Right knee: cool, dry, and intact. Skin color normal for ethnicity, no cyanosis or pallor.

Mild swelling and tenderness noted to right knee.

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp; Eyes: Sclera

clear, conjunctiva white; Ears: Tympanic membranes gray and intact; Nares: Patent with no

exudate. Throat: moist with no lesions; Neck: No lymphadenopathy.

Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored

Cardiovascular: Heart S1 and S2 noted, RRR, no murmurs, noted.

Musculoskeletal: Right Knee: decreased range of motion, crepitus, mild joint effusion, and

palpable osteophytic changes at the knee joint (Kiadaliri et al., 2018).

Differential Diagnoses: Osteoarthritis, Rheumatoid arthritis, or Gout,

Osteoarthritis (M17.11)-Primary

Osteoarthritis is a chronic degenerative joint disease that is characterized by the progressive loss

or breakdown of articular cartilage in the synovial joints and disruption of tissues around the

affected joint (Ghaznavi, Altaf, Bashir, & Alam, 2017).

Osteoarthritis affect mostly women over the age of 65 years old, and the most commonly

affected joints are the lower back, knee, hip, and hands especially the base of the thumb with

symptoms developing slowly and gradually over time (Ghaznavi et al., 2017). Patients usually

present with joint pain that is aggravated by weight-bearing activities and relieved by rest. The

patient has no systemic symptoms but usually awakens with morning stiffness that lasts less than

thirty minute, and relieved with activity. In addition to chronic joint stiffness and pain, the

patient may report episodes of acute synovitis (Ghaznavi et al., 2017). Physical examination

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