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NR 511 Week 6 Case Study Part One
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Running head: Week six case study1
Differential Diagnosis and Primacy Care Practicum
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Chamberlain College of Nursing
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Course Number: NR 511
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June 11, 2019
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, 1. Summarize the history and physical (H&P) findings: date of visit: November 7, 2017
56 y/o Caucasian female presented with history of hypertension and depression. She reports to
clinic with CC of fatigue for the past 2-3 months. She describes herself as not feeling well rested
even after 8 hours a sleep per night. She is constantly tired, lacks energy to perform daily
activities. The fatigue is worsens with exertion and she has not identified any alleviating factors
or interventions to improve her energy levels.
HPI: constipation, generalized weakness, and muscle cramping intermittently to calves, cold
intolerance, as well as worsening depression due to feeling unproductive. She denies sleep
disorders and any complaints of sleep apnea. Denies suicidal or homicidal ideation. Denies
polyuria and polydipsia.
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ROS/PE On physical exam, she is alert and oriented, no apparent distress. Skin dry skin, hair
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course and thick, nails without abnormality. HEENT unremarkable. Thyroid was noted to be
midline, small and firm with no palpable mases. Heart and lung sounds normal, Abdomen
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unremarkable. Strength of extremities 5/5 throughout and DTRs there were 2+ at bilateral biceps,
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but 1+ at both knees and ankles. BP 146/95, Height 5”7” and Weight 180 pounds.
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She has a family history of Type 2 DM, HTN, HLD and heart disease. She has a 24 year old
child with bipolar depression, ADHD, anxiety.
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PSH married, with 2 kids (adult). She is an office manager in a physician office full time. Nnon-
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smoker, drinks infrequently
Allergies include iodine dyes.
Current medications: Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Multivitamin, B-Complex,
Calcium 500mg + Vit D3 400IU.
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2. Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief
complaint along with a brief statement of pathophysiology for each
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Diagnosis #1: Hypothyroidism
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Hypothyroidism is a metabolic disorder which results from decreased free thyroid hormone or
resistant of hormone action. It is condition in which the thyroid gland is not able to produce
enough thyroid hormone. Hyperthyroidism is more prevalent in women then in men. There are
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two fairly common causes of hypothyroidism, the first. Autoimmune, (Hashimoto's thyroiditis), a
form of thyroid inflammation caused by the patient's own immune system. The second cause is
the broad category of "medical treatments." The treatment of many thyroid conditions warrants
surgical removal of a portion or all of the thyroid gland. Signs and symptoms may include
fatigue, weakness, cold intolerance, muscle cramps, weight gain and depression. (Jonklaas J,
Bianco AC, Bauer AJ, et al, 2014).
This study source was downloaded by 100000805705997 from CourseHero.com on 12-09-2021 21:15:02 GMT -06:00
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