NR 511 Week 6 Case Study Discussion - Part 1
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$20.00
| Term | July/August 2018 |
| Institution | Chamberlain |
| Contributor | James |
NR 511 Week 6 Case Study Discussion
Part One
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. |
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 |
Psych | Mood pleasant and appropriate. |
Musculoskeletal | Strength full throughout |
Neuro | DTRs 2+ at biceps, 1+ at knees and ankles |
- Briefly and concisely summarize the H&P findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information.
- Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement of pathophysiology for each.
- Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
- Rank the differential in order of most likely to least likely.
- Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM.
| Instituition / Term | |
| Term | July/August 2018 |
| Institution | Chamberlain |
| Contributor | James |
