NR511 week 6 discussion 1

Week 6: Discussion Part One

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.

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. IF you ordered a test or performed a
procedure, identify the corresponding Current Procedural Terminology (CPT)
code(s). If not applicable, list n/a. 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.

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