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.

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 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)  

Week 6 Discussion

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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 of 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)

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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  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
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

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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

Week 6 Discussion

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1.    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.
2.    Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement of pathophysiology for each.
3.    Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
4.    Rank the differential in order of most likely to least likely.
5.    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. If no testing is indicated or needed, you must also support this decision with EBM.

Week 6 Discussion

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Week 6 Discussion

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