1. List pertinent positives  & negatives

2. What other information would you need?

3. List 3 possible differentials diagnosis

4. How would you care for this patient using guidelines?

CC:  “I’m always tired”

HPI: JL 71 y.o. F reports feeling tired for the last three months but recently has noticed shortness of breath when walking up the steps and sleeping more. She denies CP, weight gain/loss, poor appetite or swelling. She denies abdominal pain, N/V/D. She denies vaginal bleeding, bloody or dark tarry stools. She has noticed some issues with her memory as well. She denies taking NSAIDs, or ETOH use. She had a normal colonoscopy 5 years ago.

PMH: GERD 2016. Depression 2000.

Surgical history: R Lumpectomy 1999. Cscope/EGD 5 years ago.

Allergies: No known drug allergy.

Medications:

Omeprazole 20mg PO daily

Sertraline 50 mg PO daily

Social History: She is retired and lives with her wife and they live off their pensions and SSI. The couple lives alone and follow a vegetarian diet. Denies alcohol, illicit drug use, tobacco use.

Family History Her brother, and 2 sisters are alive and well; not diagnosed with any chronic condition. Her parents are deceased, and not diagnosed with any chronic condition. Paternal grandmother was diagnosed with hypertension, while paternal grandfather suffered from heart disease.

Health Maintenance UTD on all immunizations and cancer screenings for age. Has had diabetes, HTN and cholesterol screenings which were all within normal limits.

Review of Systems

General: Denies fever, chills, sleeping difficulties, and weight loss/gain. Denies poor appetite lightheadedness or dizziness. Has been sleeping more and fatigue. Reports eating a healthy vegetarian diet.

HEENT: Denies earache, nasal discharge, headache, or sore throat. Denies visual abnormalities. Respiratory: Denies cough, trouble breathing nor wheezing. Has noticed shortness of breath with going up her steps at home or physical activity. CV: Denies chest pain, palpitations and leg edema.

GI: Denies Abd pain, N/V/D. No bloody or dark tarry stool

GYN: Denies vaginal bleeding

GU: Denies dysuria, hesitancy and hematuria.

MSS: No joint pain nor swelling. NS: Patient denies weakness in strength, headache, headache. Does notice some numbness and tingling at times. Has noticed more forgetfulness at times.

Skin: No rashes or lesions. Wife reports pale appearance.

Psychiatric: She feels like her depression is currently well managed. Denies anxiety.

Objective Data – 125/95mmHg. – 88 bpm. -17RR. -98.5 degrees Fahrenheit, Oxygen saturation – 100%. – Height – 5 feet 4 in. – Weight – 130 pounds.

Constitutional: Alert, oriented, dressed appropriate, pale appearance.

HEENT: Normocephalic. Lids/lashes/orbit unremarkable. Conjunctiva pale. No discharge. PERRL, EOMI. External ear canals no abnormalities observed. Angular cheilitis. Tongue smooth and beefy appearance

Neck: Supple with no lymphadenopathy nor masses. No thyromegaly noted. No tracheal deviation. Normal range of motion. No distended jugular veins.

Respiratory system: No deformities noted, no respiratory distress. Chest region is clear to auscultation.

CVS: Heart rate is regular, and its rhythm is normal, and slight murmur is noted. Pulses are symmetrical and regular. No evidence of a collapsing pulse.

Abdominal examination: Abdomen is soft, non-tender, non-distended, and no masses are palpable. Bowel sounds normal. No hepatosplenomegaly nor rebound tenderness.

MSS: Extremities are warm, without ulcerations or edema.

Neuro: Oriented x4 and walks with normal gait. Muscle tone in all limbs is 5/5. CN II-XII intact. PERRLA +6mm. Cerebellar exam intact. Decrease vibratory sensation noted to hands/feet. Skin: Skin is warm, pale and dry. No rashes nor erythema noted. Psychiatric: Patient oriented x4. No suicidal nor homicidal tendencies