NR511 Week 6 Case Study Part 1 Sept 2019
History of Present Illness:
A 56-year-old Caucasian female who presents to the office with complaints of feeling
fatigued for the last 2-3 months. She reported that the feeling is generalized and
constant and the feeling is exacerbated with exertion. There are no relieving factors and
.
she reports it has getting increasingly worse since onset, she feels tired all of the time
although she gets 8hrs of sleep, she does not feel well rested. She reported she has
“No energy to do anything I normally can do”. She denies having pain but reported she
missed 1 day of work 2 weeks ago because she “couldn’t’ get out of bed”. No form of
treatments has been done at this time.
Review of Symptoms
Constitutional: Denies fever, denies chills, or any recent illnesses. She reports a 5-
pound wgt gain since her last office visit 6 months ago.
HEENT: Negative. No visual changes or diplopia. Denies coryza, ear pain, rhinorrhea,
or ST. She reports having tonsillectomy as child. She denies having any issues with
snoring or any history of sleep apnea. Denies lymph node tenderness or swelling.
Cardiovascular symptoms: Negative. Denies cough CP, cough, SOB, DOE or
wheezing.
Gastrointestinal symptoms: Denies N/V/D + Constipation.
Endocrine symptoms: Denies polyuria, polydipsia. + cold intolerance. Menopause
status x5 years.
Skin symptoms: Negative. No changes in skin, hair, or nails.
Psychiatric symptoms: Negative for SI/HI. Denies having any changes in her sleep
pattern, gets 8-9hrs of sleep per night but not feeling rested Reports worsening of
depressive symptoms but contributes it to being “unproductive” and tired all of the time.
Musculoskeletal symptoms: Generalize weakness and intermittent muscle cramping
in calves
Health Status
Allergies: Iodine dyes
Medications: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg,
Calcium 500mg + Vit D3 400IU.
PM / Family / Social History
Medical history: HTN, Depression, Postmenopausal status
PSH: Tonsillectomy
Family history: Maternal GM & GF deceased with CHF, T2DM & HTN; Mother alive
(82-y.o) +HTN, +hyperlipidemia, +T2DM; Father alive (84-y.o.) +HTN, +Hyperlipidemia,
, +T2DM, +ASHD (s/p +DVT & +PFO; remains anticoagulated); G2P2. Her oldest child
(26 y.o.) has seasonal allergies, youngest child (24 y.o.) has bipolar depression and
ADHD & anxiety
Social history: Employed F/T, Family / social situation: Married with 2 adult children,
denies smoking cigarettes or illicit drug use. Drinks wine (1-2 glasses p/month) socially.
Physical Examination
Constitutional: Middle aged. Caucasian female alert and oriented x3 and cooperative
Vital Signs: BP 146/95, Temp 98.2, P 74, RR 16, Hgt 5’7”, Wgt 180lbs
HEENT: Normocephalic, atraumatic. Eyes: PERRLA. Ears: Tympanic membranes gray,
intact with light reflex noted. Nose: No bogginess no swelling. Nares patent. Nasal
drainage is clear. Throat: Oropharynx moist, no lesions or exudate. Bilateral tonsils
surgically removed. No dental caries noted. Neck: Supple, thyroid midline, small, firm,
and no palpable masses, no lymphadenopathy noted.
Cardiopulmonary: Lungs clear with auscultation respirations unlabored and S1 and S2
noted and no M/G/R. No pedal edema.
Gastrointestinal: Soft, Nontender, BS active
Skin: Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psychiatric: Mood pleasant and appropriate.
Musculoskeletal: Normal strength throughout
Neurological: DTRs 2+ at biceps, 1+ at knees and ankles
Differential Diagnoses
Hypothyroidism: is an underactive thyroid gland. The thyroid gland is unable to
produce enough of the hormone that help with the body’s metabolism. It keeps the heart
and body temperature running normal. It affects other symptoms include constipation,
cold sensitivity, fatigue, wgt gain, muscle weakness, depression, changes in memory
(trouble concentrating or remembering), hair loss, irregular menstrual cycles, and dry
skin. About 4.6 percent of the U.S. population ages 12 and older has hypothyroidism,
although most cases are mild (NIH, 2016). It is recommended that women beginning at
age 35 be screened for hypothyroidism and continued screening every 5 years after age
35. Hypothyroidism is “5 to 10 more time likely to occur in women than in men” (Dunn &
Turner, 2016).
Pertinent positive findings: depression, fatigue, changes in memory, dry skin, wgt gain,
muscle weakness, bowel changes (constipation), cold intolerance
Positive negative findings: irregular menstrual cycle, pain, puffy face, enlarged thyroid
(goiter), hoarseness, muscle aches, stiffness, thinning and or brittle hair
Type II Diabetes Mellitus is a form of diabetes that is characterized by an increase in
blood sugar, a decrease in insulin, and insulin resistance. Symptoms of type II DM
include wgt gain or wgt loss, excessive hunger, thirst, or fatigue. Other associated
symptoms include blurred vision, frequent urination, skin infections, sweet or fruity
History of Present Illness:
A 56-year-old Caucasian female who presents to the office with complaints of feeling
fatigued for the last 2-3 months. She reported that the feeling is generalized and
constant and the feeling is exacerbated with exertion. There are no relieving factors and
.
she reports it has getting increasingly worse since onset, she feels tired all of the time
although she gets 8hrs of sleep, she does not feel well rested. She reported she has
“No energy to do anything I normally can do”. She denies having pain but reported she
missed 1 day of work 2 weeks ago because she “couldn’t’ get out of bed”. No form of
treatments has been done at this time.
Review of Symptoms
Constitutional: Denies fever, denies chills, or any recent illnesses. She reports a 5-
pound wgt gain since her last office visit 6 months ago.
HEENT: Negative. No visual changes or diplopia. Denies coryza, ear pain, rhinorrhea,
or ST. She reports having tonsillectomy as child. She denies having any issues with
snoring or any history of sleep apnea. Denies lymph node tenderness or swelling.
Cardiovascular symptoms: Negative. Denies cough CP, cough, SOB, DOE or
wheezing.
Gastrointestinal symptoms: Denies N/V/D + Constipation.
Endocrine symptoms: Denies polyuria, polydipsia. + cold intolerance. Menopause
status x5 years.
Skin symptoms: Negative. No changes in skin, hair, or nails.
Psychiatric symptoms: Negative for SI/HI. Denies having any changes in her sleep
pattern, gets 8-9hrs of sleep per night but not feeling rested Reports worsening of
depressive symptoms but contributes it to being “unproductive” and tired all of the time.
Musculoskeletal symptoms: Generalize weakness and intermittent muscle cramping
in calves
Health Status
Allergies: Iodine dyes
Medications: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg,
Calcium 500mg + Vit D3 400IU.
PM / Family / Social History
Medical history: HTN, Depression, Postmenopausal status
PSH: Tonsillectomy
Family history: Maternal GM & GF deceased with CHF, T2DM & HTN; Mother alive
(82-y.o) +HTN, +hyperlipidemia, +T2DM; Father alive (84-y.o.) +HTN, +Hyperlipidemia,
, +T2DM, +ASHD (s/p +DVT & +PFO; remains anticoagulated); G2P2. Her oldest child
(26 y.o.) has seasonal allergies, youngest child (24 y.o.) has bipolar depression and
ADHD & anxiety
Social history: Employed F/T, Family / social situation: Married with 2 adult children,
denies smoking cigarettes or illicit drug use. Drinks wine (1-2 glasses p/month) socially.
Physical Examination
Constitutional: Middle aged. Caucasian female alert and oriented x3 and cooperative
Vital Signs: BP 146/95, Temp 98.2, P 74, RR 16, Hgt 5’7”, Wgt 180lbs
HEENT: Normocephalic, atraumatic. Eyes: PERRLA. Ears: Tympanic membranes gray,
intact with light reflex noted. Nose: No bogginess no swelling. Nares patent. Nasal
drainage is clear. Throat: Oropharynx moist, no lesions or exudate. Bilateral tonsils
surgically removed. No dental caries noted. Neck: Supple, thyroid midline, small, firm,
and no palpable masses, no lymphadenopathy noted.
Cardiopulmonary: Lungs clear with auscultation respirations unlabored and S1 and S2
noted and no M/G/R. No pedal edema.
Gastrointestinal: Soft, Nontender, BS active
Skin: Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psychiatric: Mood pleasant and appropriate.
Musculoskeletal: Normal strength throughout
Neurological: DTRs 2+ at biceps, 1+ at knees and ankles
Differential Diagnoses
Hypothyroidism: is an underactive thyroid gland. The thyroid gland is unable to
produce enough of the hormone that help with the body’s metabolism. It keeps the heart
and body temperature running normal. It affects other symptoms include constipation,
cold sensitivity, fatigue, wgt gain, muscle weakness, depression, changes in memory
(trouble concentrating or remembering), hair loss, irregular menstrual cycles, and dry
skin. About 4.6 percent of the U.S. population ages 12 and older has hypothyroidism,
although most cases are mild (NIH, 2016). It is recommended that women beginning at
age 35 be screened for hypothyroidism and continued screening every 5 years after age
35. Hypothyroidism is “5 to 10 more time likely to occur in women than in men” (Dunn &
Turner, 2016).
Pertinent positive findings: depression, fatigue, changes in memory, dry skin, wgt gain,
muscle weakness, bowel changes (constipation), cold intolerance
Positive negative findings: irregular menstrual cycle, pain, puffy face, enlarged thyroid
(goiter), hoarseness, muscle aches, stiffness, thinning and or brittle hair
Type II Diabetes Mellitus is a form of diabetes that is characterized by an increase in
blood sugar, a decrease in insulin, and insulin resistance. Symptoms of type II DM
include wgt gain or wgt loss, excessive hunger, thirst, or fatigue. Other associated
symptoms include blurred vision, frequent urination, skin infections, sweet or fruity
