Judgments NR 511 / NR511 (NR511) NR 511 Week 6: Clinical Case Study Part One Discussion
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Course
NR 511 / NR511 (NR511)
Institution
Chamberlain College Of Nursing
(Answered) NR511 Week 6: Clinical Case Study Part One Discussion Week 6: Clinical Case Study Part One Discussion No unread replies.No replies. Purpose Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving ac...
HPI:
A 56-year-old Caucasian female presents to the office today with complaints of generalized
fatigue for the last 2-3 months 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 well-
rested. 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 (84-y.o.) +HTN, +Hyperlipidemia, +T2DM,
+ASHD (s/p +DVT & +PFO; remains anticoagulated); Oldest child (26 y.o.) has seasonal
allergies, youngest child (24 y.o.) has bipolar depression and ADHD & anxiety
Social hx: Employed F/T, she is married with 2 adult children, denies smoking cigarettes or
illicit drug use. Drinks wine (1-2 glasses p/month) socially.
Physical Examination
Constitutional: Middle-aged, caucasian female AxO and cooperative
Vital Signs: BP 146/95, Temp 98.2, P 74, RR 16, Hgt 5’7”, Wgt 180lbs
HEENT: Head normocephalic, atraumatic. Eyes PERRLA. The tympanic membranes are gray,
intact with light reflex noted. Nares patent; turbinates no bogginess, no swelling, nasal drainage
is clear. Oropharynx moist, no lesions or exudate. Bilateral tonsils surgically removed. No dental
caries noted. Neck supple, thyroid small, firm, & midline no palpable masses; no
lymphadenopathy noted.
Cardiopulmonary: Lungs clear b/l with auscultation respirations unlabored and S1 and S2
noted and no M/G/R. No pedal edema.
GI: Soft, non-tender, BS active x 4 quad
Skin: Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psych: Mood pleasant and appropriate.
Msk: Normal strength throughout
Neurological: DTRs 2+ at biceps, 1+ at knees and ankles
DDx:
Hypothyroidism: In hypothyroidism, the thyroid gland (TH) does not produce enough thyroid
hormome. TH is “regulated by TRH through a negative-feedback loop that involves the anterior
pituitary and hypothalamus” (McCance, Huether, Brashers, & Rote, 2019). Disruption of the TH
will affect bodily functions such as how the body regulates temperature, heart rate, and all
aspects of metabolism (McCance, Huether, Brashers, & Rote, 2019). The patient will report cold
intolerance, constipation, weight gain, hoarseness, enlarged thyroid, decrease pulse rate, coarse
dry hair, symptoms of depression, and fatigue (Dains, Baumann, & Scheibel, 2020, p.15).
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