Date of visit: November 7, 2017
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
"about 2-3 months"
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"
Denies pain; missed 1 day of work 2 weeks ago because "couldn't get out of bed"
Review of Systems (ROS)
Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.
No visual changes or diploplia
Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.
Denies lymph node tenderness or swelling
Denies cough, SOB, DOE or wheezing
Denies chest pain
Denies N/V/D. + Constipation
Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
No changes in skin, hair or nails
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
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).
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 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 reveals the following:
Middle aged Caucasian female alert, oriented and cooperative
Temp-98.2, P-74, R-16, BP 146/95, Height: 5'7", Weight: 180 pounds
Tympanic membranes gray and intact with light reflex noted.
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. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema
Soft, non-tender. BS active
Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Mood pleasant and appropriate.
Strength full throughout
DTRs 2+ at biceps, 1+ at knees and ankles
Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results.
CBC with differential
4.44 x 10E6/uL
241 x 10E3/uL
5.7 x 10E3/uL
1.9 x 10E3/uL
0.7 x 10E3/uL
0.3 x 10E3/uL
0.0 x 10E3/uL
Immature Grans %
Absolute Immature Grans
0.0 x 10E3/uL
TSH with Reflex to FT4
PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)
*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
Preview of NR511-week-6-discussion-part-2---2018.docx
Preview of NR511-week-6-discussion-part-1--2018.docx