NR 511 Week 6 Case Study
Discussion Part 1
Date of visit: November 7, 2017
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.
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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).
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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.
Nose Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.
Throat Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally.
Teeth in good repair, no cavities.
Neck Neck supple. No lymphadenopathy. Thyroid midline, small and firm without
palpable masses.
Cardiopulmonary Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally.
Respirations unlabored. No pedal edema
Abdomen Soft, non-tender. BS active
Skin Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
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