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. Medical history: HTN, Depression, Postmenopausal status PSH: Tonsillectomy