A 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.
Case analysis: 56-year-old Caucasian female
First, briefly and concisely summarize the history and physical (H&P) findings as if you were presenting it to your preceptor using the pertinent facts from the case. Further, Use shorthand where possible and approved medical abbreviations. Morever, avoid redundancy and irrelevant information.
Fut-her, Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement of pathophysiology for each.
Additionally, Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. Morever, Rank the differential in order of most likely to least likely for the 56-year-old Caucasian female.
Further questions: 56-year-old Caucasian female
Finally, identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. Additionally, If no testing is indicated or needed, you must also support this decision with EBM evidence.
History of Present Illness: 56-year-old Caucasian female
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”
First, Aggravating factors for the 56-year-old Caucasian female
futher, Relieving factors
Denies pain; missed 1 day of work 2 weeks ago because “couldn’t get out of bed”
Review of Systems (ROS): 56-year-old Caucasian female
further, Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.
Morever, No visual changes or diploplia
Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.
Denies chest pain
Denies N/V/D. + Constipation
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.
Generalized weakness and intermittent muscles cramping in calves for the 56-year-old Caucasian female
Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.
HTN, Depression, Postmenopausal status
Married; Works full time as office manager of an internal medicine office; 2 kids (grown)
Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month).
Physical exam reveals the following
Physical Exam for the 56-year-old Caucasian female
Middle aged Caucasian female alert, oriented and cooperative
Tympanic membranes gray and intact with light reflex noted for the 56-year-old Caucasian female
Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.
Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
Heart S1 and s2 noted, no murmurs, noted. Further, Lungs clear to auscultation bilaterally. Additionally, Respirations unlabored. Finally, No pedal edema
Abdomen- 56-year-old Caucasian female
Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Medications: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.
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);
Reports worsening of depressive symptoms but thinks it is because she is so “unproductive” lately and tired all of the time. Further, he henies Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested.