*NURSING > CASE STUDY > Rana Liaquat Ali Khan Govt. CollegeNUR HEALTH ASSNR511 Week 6 Case Study. (All)

Rana Liaquat Ali Khan Govt. CollegeNUR HEALTH ASSNR511 Week 6 Case Study.

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NR511 Week 6 Case Study CC: “Fatigue” History of Present Illness: This is a 56-year-old Caucasian female who presents to the office today with complaints of constantly feeling fatigued for the... last 2-3 months. She reported this is a generalized feeling and the feeling is aggravated on exertion. There are no relieving factors and she reports it has gotten progressively 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, chills, or recent illnesses. Reports a 5lb weight gain since her last office visit 6 months ago. HEENT: Negative. No visual changes or diplopia. Denies ear pain, coryza, rhinorrhea, or ST. Had a tonsillectomy as child. Denies snoring or history of sleep apnea. Denies lymph node tenderness or swelling. Cardiovascular symptoms: Negative. Denies CP, cough, SOB, DOE or wheezing. Gastrointestinal symptoms: Denies N/V/D + Constipation. Endocrine symptoms: Denies polyuria, polydipsia. + cold intolerance. Menopause status x5 years. Skin symptoms: Negative. No changes in skin, hair, or nails. Psychiatric symptoms: Reports worsening of depressive symptoms but contributes it 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 symptoms: Generalize weakness and intermittent muscle cramping in 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 [Show More]

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Dr Medina Reed

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