Chamberlain College of NursingNR 511NR511 Week 6 Case Study.

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Greetings Professor and class, 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 m... onths 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 wellrested. 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 Family hx: Maternal GM & GF deceased with CHF, T2DM & HTN; Mother alive (82-y.o) +HTN, +hyperlipidemia, +T2DM; Father alive ( [Show More]

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