NR 511 Week 6 Case Study Discussion Part 1 A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further
... [Show More] questioning you discover the following subjective information regarding the chief complaint. History of Present Illness Onset "about 2-3 months" Location Generalized Duration Constant Characteristics Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested. "No energy to do anything I normally can do" Aggravating factors Exertion Relieving factors None identified Treatments None Severity Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of bed" Review of Systems (ROS) Constitutional Denies fever, chills, or recent illnesses. 5lb. weight gain since last visit 6 months ago. Eyes No visual changes or diploplia ENT Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea. Neck Denies lymph node tenderness or swelling Chest Denies cough, SOB, DOE or wheezing Heart Denies chest pain Abdomen Denies N/V/D. Constipation Endocrine Denies polyuria, polydipsia. cold intolerance. Menopause status x 5 yrs. Skin No changes in skin, hair or nails Psych Reports 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. Musculoskeletal Generalized weakness and intermittent muscles cramping in calves History Medications Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg Vit D3 400IU. PMH HTN, Depression, Postmenopausal status PSH Tonsillectomy Allergies Iodine dyes Social Married; Works full time as office manager of an internal medicine office; 2 kids (grown) Habits Denies cigarettes or drug use. Occasional glass of wine (1-2 per month). FH Maternal GM & GF deceased with CHF, T2DM and HTN; Mother alive (age 82) HTN, Hyperlipidemia, T2DM; Father alive (age 84) HTN, Hyperlipidemia, T2DM, ASHD (s/p CABG 2 years ago). Also had CVA at time of CABG (work-up revealed DVT and PFO; remains anticoagulated); Oldest child (26) with seasonal allergies Youngest child (24) with Bipolar depression and ADHD, and anxiety Physical exam reveals the following: Physical Exam Constitutional Middle aged Caucasian female alert, oriented and cooperative VS Temp-98.2, P-74, R-16, BP 146/95, Height: 5'7", Weight: 180 pounds Head Normocephalic, atraumatic Eyes PERRLA Ears Tympanic membranes gray and intact with light reflex noted. Nose Nares patent. Nasal turbinates without swelling. Nasal drainage is clear. Throat Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities. Neck Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema Abdomen Soft, non-tender. BS active Skin Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration Psych Mood pleasant and appropriate. Musculoskeletal Strength full throughout Neuro DTRs 2 at biceps, 1 at knees and ankles • Briefly and concisely summarize the H&P findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information. • Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement of pathophysiology for each. • Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. Rank the differential in order of most likely to least likely. • Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. IF you ordered a test or performed a procedure, identify the corresponding Current Procedural Terminology (CPT) code(s). If not applicable, list n/a. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM. Type the body of your Discussion Post here. Discussion Posts put the Reference Section on the same page to make it easy to copy and paste it into an online forum. We've already added your Reference Section below. References Dr. Turner and class, This is a 53 years old women presenting to the office complaining of fatigue which started about 2 to 3 months ago and has progressively increased. She also complaints of symptoms getting worse with activity and reports that nothing has helped to decreased the them. She reports that she has been sleeping at least 8 hours every night but wakes up with not well-rested feeling and has no energy to do any of the things she normally does; she had to miss work at least one time because she could not get out of bed. She states that she thinks she has been very unproductive lately and this is causing her Depression symptoms to worsen. Her weight has increased 5lb since last visit. The patient’s medical history includes Hypertension, Depression, and she has been menopausal for 5 years. The only surgical history is Tonsillectomy during childhood. Her medications include: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg Vit D3 400IU. Her physical exam was negative except for dry skin, hair is coarse and dry and her DTRs 2 at biceps, and 1 at knees and ankles. Based on her symptoms I believe that the following diagnosis can be deducted: Worsening Depression, Hypothyroidism, or Chronic Fatigue Syndrome. Depression is disease with basically unknown causes. However healthcare experts in te field of mental health treatment and mental health research argue that causes are mostly related to chemical imbalances or metabolic disorders some in the field on mental health care believe the illness can have cause by a physiological or metabolic related (Furhan, Ritchie & Lay, 2016). Depression symptoms include: decreased interest and pleasure in things one has enjoyed doing before, fatigue, inability to concentrate, feeling worthless, decreased sexual drive, weight loss or gain, insomnia or hypersomnia, and decreased or increased appetite. Some patients may present other symptoms such as irritability, paranoia, delusions, feelings of impending death, and Hallucinations (Ayis et al., 2016). Hypothyroidism is basically a decreased in Thyroid function. The disease may have several causes such as decreased Thyroid gland function, Thyroid gland resection, decreased Pituitary function (Hypopituitarism), decreased Iodine intake, and many times is the result of medication side-effects. Symptoms include fatigue, weight gain, lethargy, depression, cold intolerance, decreased heart rate, decreased TSH lab value, dry skin, headache, and paresthesia (Persani & Bonomi, 2017). Chronic Fatigue syndrome is an disease of unknown cause. However, it has been determined to be related to several diseases. Based on several studies revealed that those suffering from Chronic Fatigue Syndrome have co-morbidities such as CAD, DM type I and II, Depression, CA, Hypothyroidism and HIV infection. Major symptoms include decreased energy, generalized weakness, mental fatigue, decreased concentration and decreased memory (Smith et al., 2015). In conclusion, I believe the patient is suffering from worsening of her Depression (ICD code: F33.9). Her medication should be increased to Prozac 20mg, and she should be reassured that her symptoms will hopefully improve. She should also be referred to a Psychiatrist so that she can start with therapy. Additionally, she needs to be advice to come back within two weeks if symptoms do not improve or worsen; if she has not stablished a visit with a Psychiatrist yet. Although some of her symptoms are pointing to Hypothyroidism (ICD code: I03.9), before that diagnosis could be done she would have to have labs done (CBC, TSH, BUN,Creat, Iodine level) and also an X-ray to evaluate thyroid size. According to studies done Chronic Fatigue Syndrome (ICD code: I53.82), is closely related to Depression. In order to determine if this is the problem the patient needs to be further evaluated by a Psychiatrist that can determine if her depression is under control and her symptoms are related to other diseases such as this one. References Ayis, S. A., Ayerbe, L., Crichton, S. L., Rudd, A. G., & Wolfe, C. D. (2016). The natural history of depression and trajectories of symptoms long term after stroke: The prospective south London stroke register. Journal of affective disorders, 194, 65-71. Furnham, A., Ritchie, W., & Lay, A. (2016). Beliefs about the causes and cures of depression. International Journal of Social Psychiatry, 62(5), 415-424. Persani, L., & Bonomi, M. (2017). The multiple genetic causes of central hypothyroidism. Best Practice & Research Clinical Endocrinology & Metabolism, 31(2), 255-263. Smith, M. B., Haney, E., McDonagh, M., Pappas, M., Daeges, M., Wasson, N., ... & Nelson, H. D. (2015). Treatment of myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of internal medicine, 162(12), 841-850. [Show Less]
