Exam (elaborations)
NR511 Week 6 Discussion Template
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NR511 Week 6 Discussion Template
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A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Uponfurther questioning you discover the following subjective information regarding the chief
complaint.
History of Present Illness
Onset "about 2-3 months"
Location Generalized
Duration Constant
Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per
Characteristics night but does not feel well rested. "No energy to do anything I normally can
do"
Aggravating
Exertion
factors
Relieving factors None identified
Treatments None
Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of
Severity
bed"
Review of Systems (ROS)
Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6
Constitutional
months ago.
Eyes No visual changes or diploplia
This study source was downloaded by 100000830246019 from CourseHero.com on 08-01-2022 14:10:20 GMT -05:00
https://www.coursehero.com/file/32667648/NR511-Week-6-Discussion-Templatedocx/
, Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies
ENT
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
Reports worsening of depressive symptoms but thinks it is because she is so
Psych "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
Medication Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg,
s Calcium 500mg + Vit D3 400IU.
PMH HTN, Depression, Postmenopausal status
PSH Tonsillectomy
This study source was downloaded by 100000830246019 from CourseHero.com on 08-01-2022 14:10:20 GMT -05:00
https://www.coursehero.com/file/32667648/NR511-Week-6-Discussion-Templatedocx/
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