NR511 Week 6 Case Study.
NR511 Week 6 Case Study.
Greetings Professor and class,
NR511 Week 6 Case Study
CC: “Fatigue”
HPI:
A 56-year-old Caucasian female presents to the office today with complaints of generalized
fatigue for the last 2-3 months and worsens on exertion, thus causing progressive worsening
since onset. She reports feeling tired all of the time, sleep 8hrs per night, but does not feel well-
rested. She stated that she has no energy to do the things she usually does and reported missing
“1 day of work 2 weeks ago” because she could not get out of bed. She denies pain and reported
no treatments or relieving factors.
ROS:
Constitutional: Denies fever, chills, or recent illnesses. She reported a 5lb weight gain since her
last office visit 6 months ago.
HEENT: HEENT: Negative. No visual changes or diplopia. Denies any ear pain, coryza,
rhinorrhea, or ST. She reported having a tonsillectomy as a child. Denies snoring or a history of
sleep apnea. Denies any lymph node tenderness or swelling.
Respiratory: Denies cough, SOB, DOE or wheezing
CV: Denies chest pain
GI: Denies N/V/D. + Constipation
GU: Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin: Negative. No changes in skin, hair, or nails
Psych: Reports worsening of depressive symptoms but thinks it might be contributed to being
“unproductive” and tired all of the time. Negative for SI/HI. No changes in sleep pattern, gets 8-
9hrs of sleep per night but not feeling rested.
Musculoskeletal: Reports generalized weakness and intermittent muscles cramping in calves
Allergies: Iodine dyes
Medications hx: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg,
Calcium 500mg & Vit D3 400IU.
, NR511 Week 6 Case Study.
Medical history: HTN, Depression, Postmenopausal status
PSH: Tonsillectomy
NR511 Week 6 Case Study.
Greetings Professor and class,
NR511 Week 6 Case Study
CC: “Fatigue”
HPI:
A 56-year-old Caucasian female presents to the office today with complaints of generalized
fatigue for the last 2-3 months and worsens on exertion, thus causing progressive worsening
since onset. She reports feeling tired all of the time, sleep 8hrs per night, but does not feel well-
rested. She stated that she has no energy to do the things she usually does and reported missing
“1 day of work 2 weeks ago” because she could not get out of bed. She denies pain and reported
no treatments or relieving factors.
ROS:
Constitutional: Denies fever, chills, or recent illnesses. She reported a 5lb weight gain since her
last office visit 6 months ago.
HEENT: HEENT: Negative. No visual changes or diplopia. Denies any ear pain, coryza,
rhinorrhea, or ST. She reported having a tonsillectomy as a child. Denies snoring or a history of
sleep apnea. Denies any lymph node tenderness or swelling.
Respiratory: Denies cough, SOB, DOE or wheezing
CV: Denies chest pain
GI: Denies N/V/D. + Constipation
GU: Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin: Negative. No changes in skin, hair, or nails
Psych: Reports worsening of depressive symptoms but thinks it might be contributed to being
“unproductive” and tired all of the time. Negative for SI/HI. No changes in sleep pattern, gets 8-
9hrs of sleep per night but not feeling rested.
Musculoskeletal: Reports generalized weakness and intermittent muscles cramping in calves
Allergies: Iodine dyes
Medications hx: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg,
Calcium 500mg & Vit D3 400IU.
, NR511 Week 6 Case Study.
Medical history: HTN, Depression, Postmenopausal status
PSH: Tonsillectomy
