Case Study Date of visit: November 7, 2017 A 56-year-old Caucasian… Case StudyDate of visit: November 7, 2017A 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 IllnessOnset”about 2-3 months”LocationGeneralizedDurationConstantCharacteristicsProgressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested.Aggravating factorsExertionRelieving factorsNone identifiedTreatmentsNoneSeverityDenies pain; missed 1 day of work 2 weeks ago because “couldn’t get out of bed” Review of Systems (ROS)ConstitutionalDenies fever, chills, or recent illnesses. ?. weight gain since last visit 6 months ago.EyesNo visual changes or diplopliaENTDenies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.NeckDenies lymph node tenderness or swellingChestDenies cough, SOB, DOE or wheezingHeartDenies chest painAbdomenDenies N/V/D. ConstipationEndocrineDenies polyuria, polydipsia. cold intolerance. Menopause status x 5 yrs.SkinNo changes in skin, hair or nailsPsychReports 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.MusculoskeletalGeneralized weakness and intermittent muscles cramping in calves HistoryMedicationsMultivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg Vit D3 400IU.PMHHTN, Depression, Postmenopausal statusPSHTonsillectomyAllergiesIodine dyesSocialMarried; Works full time as office manager of an internal medicine office; 2 kids (grown)HabitsDenies cigarettes or drug use. ??? glass of wine (1-2 per month).FHMaternal GM & GF deceased with CHF, T2DM and HTN;Mother alive (age 82) ?, ?????, ?;Father alive (age 84) ?, ?????, ?, g (s/p CABG 2 years ago). Also had ? at time of CABG (work-up revealed ? and ?; remains anticoagulated);Oldest child (26) with seasonal allergiesYoungest child (24) with Bipolar depression and ADHD, and anxietyPhysical exam reveals the following:Physical ExamConstitutionalMiddle aged Caucasian female alert, oriented and cooperativeVSTemp-98.2, P-74, R-16, BP 146/95, Height: 5’7″, Weight: 180 poundsHeadNormocephalic, atraumaticEyesPERRLAEarsTympanic membranes gray and intact with light reflex noted.NoseNares patent. Nasal turbinates without swelling. Nasal drainage is clear.ThroatOropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.NeckNeck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.CardiopulmonaryHeart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edemaAbdomenSoft, non-tender. BS activeSkinSkin overall dry, hair coarse and thick, nails without ridging, pitting or discolorationPsychMood pleasant and appropriate.MusculoskeletalStrength full throughoutNeuroDTRs 2 at biceps, 1 at knees and ankles **To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric. DISCUSSION CONTENT Category Points % Description Application of Course Knowledge 15 30% A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; ANDThree (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; ANDA brief statement of pathophysiology is included for each diagnosis; ANDEach diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; ANDThe differential is ranked in order from most likely to least likely; ANDClinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; ANDTesting decisions are well supported with EBM arguments that are in-line with the clinical scenario and appropriate for the primary care setting (7 critical elements) Support from Evidence-Based Practice (EBP) 15 30% Discussion post is supported with appropriate, scholarly sources; AND  Sources are published within the last 5 years (unless it is the most current CPG); AND Reference list is provided and in-text citations match; AND All testing decisions are fully supported with an appropriate EBM argument (4 critical elements) Interactive Dialogue 10 20% Student provides a substantive* response to at least one topic-related post of a peer; AND Evidence from appropriate scholarly sources are included; AND Reference list is provided and in-text citations match; AND Student responds to all direct faculty questions  (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response (4 critical elements)     Health ScienceScienceNursing FNP NR511

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