NR 511 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

Psych Reports worsening of depressive symptoms but

thinks it is because she is so "unproductive" lately

and tired all of the time. -Suicidal or homicidal

thoughts. Sleeping 8-9hrs per night (no changes),

but not feeling rested.

Musculoskeletal Generalized weakness and intermittent muscles

cramping in calves

History

Medications Multivitamin, B-Complex, Prozac 20mg,

Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg +

Vit D3 400IU.

PMH HTN, Depression, Postmenopausal status

PSH Tonsillectomy

Allergies Iodine dyes

Social Married; Works full time as office manager of an

internal medicine office; 2 kids (grown)

Habits Denies cigarettes or drug use. +Occasional glass

of wine (1-2 per month).

FH Maternal GM & GF deceased with CHF, T2DM

and HTN;

Mother alive (age 82) +HTN, +Hyperlipidemia,

+T2DM;

Father alive (age 84) +HTN, +Hyperlipidemia,

+T2DM, +ASHD (s/p CABG 2 years ago). Also had

+CVA at time of CABG (work-up revealed +DVT

and +PFO; remains anticoagulated);

Oldest child (26) with seasonal allergies

Youngest child (24) with Bipolar depression and

ADHD, and anxiety

Physical exam reveals the following:

Physical Exam

Constitutional Middle aged Caucasian female alert, oriented and

cooperative

VS Temp-98.2, P-74, R-16, BP 146/95, Height: 5'7",

Weight: 180 pounds

Head Normocephalic, atraumatic

Eyes PERRLA

Ears Tympanic membranes gray and intact with light

reflex noted.

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