NR 511 week 6 discussion
1Differential Diagnosis & Primary
Care Practicum A+
, Hello Dr. and class,
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.
Patient is a 56- year- old Caucasian female presenting to the office with complaint of fatigue
which began 2-3 months ago and has progressively gotten worse. She also complains of
symptoms getting worse with activity and reports that nothing has helped to decreased them. She
states that despite getting 8 hours of sleep nightly she constantly feels tired and has “no energy to
do anything I normally can do”. She also reports having missed a day of work because she
“couldn’t get out of bed”. Pt states that fatigue is aggravated by exertion and that there are no
relieving factors. She has not tried any OTC or home remedies. Pt also reports that she has had
worsening depression and a 5-pound weight gain over the last six months.
Patient denies SI/HI. In addition, she reports that she has been having intermittent muscle cramps
in her calves. She denies fever, chills, SOB, CP, wheezing, cough, N/V/D, ear pain, snoring,
sleep apnea. Denies smoking. Negative for swelling, lymphadenopathy. Appropriate mood, full
strength throughout. Positive for constipation, cold intolerance, and dry skin. 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 and Vit D3 400IU.
1. Provide a differential diagnosis (minimum of 3) which might explain the patient's chief
complaint along with a brief statement of pathophysiology for each.
Hypothyroidism (ICD10: E03.9)
Hypothyroidism is basically a decrease in thyroid function. Thyrotropin-releasing hormone
(TRH) is produced in the hypothalamus and stimulates the anterior pituitary to secrete
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