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 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)
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 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)
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 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:
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
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
- 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.
- Provide a differential diagnosis (minimum of 3) which might explain the patient's chief complaint along with a brief statement of pathophysiology for each.
- Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. Rank the differential in order of most likely to least likely.
- Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. IF you ordered a test or performed a procedure, identify the corresponding Current Procedural Terminology (CPT) code(s). If not applicable, list n/a. 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.