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NR 511 Week 6: Clinical Case Study Part One Discussion - A 56-year-old Caucasian female presents to the office today with complaints of fatigue | (GRADED A+) | Download To Score An A $10.99
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NR 511 Week 6: Clinical Case Study Part One Discussion - A 56-year-old Caucasian female presents to the office today with complaints of fatigue | (GRADED A+) | Download To Score An A
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(Answered) NR511 Week 6: Clinical Case Study Part One Discussion Week 6: Clinical Case Study Part One Discussion No unread replies.No replies. Purpose Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving ac...

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  • February 8, 2022
  • 11
  • 2021/2022
  • Case
  • Nursejolly
  • A+

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  • nr 511 week 6 clinical case study part one discussion a 56 year old caucasian female presents to the office today with complaints of fatigue | graded a | download to score an a

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NR511 Week 6: Clinical Case Study Part One Discussion
NR511 Week 6 Case Study Part 1

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 andshe 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 orwheezing.
Gastrointestinal symptoms: Denies N/V/D + Constipation.
Endocrine symptoms: Denies polyuria, polydipsia. + cold intolerance. Menopausestatus 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 crampingin
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 S2noted
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 inblood
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

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