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
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