Wk5Assgn+Walton+Helen.doc - 1 Hypothyroid Iron-Deficiency Anemia or Depression Helen Walton Walden University NURS-6512N 52 Advanced Health Assessment

Wk5Assgn+Walton+Helen.doc - 1 Hypothyroid Iron-Deficiency...

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1 Hypothyroid, Iron-Deficiency Anemia, or Depression Helen Walton Walden University NURS-6512N, 52, Advanced Health Assessment and Diagnostic Reasoning December 28, 2019
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2 Hypothyroid, Iron-Deficiency Anemia, or Depression Chantel is a 32-year-old female whom presents today with complaints of fatigue, and with concern that her hair is falling out. Chantel also reports that she is having difficulty sleeping most nights and that she is feeling cold the majority of time. Although Chantel reports a marked reduction in appetite, she has noted a 30-pound increase in her weight over the last year. Chantel states that she does not believe she is depressed as she is still enjoying her hobbies. Patient Initials: C. Age: 32 Gender: Female SUBJECTIVE: “I am feeling tired all the time and my hair is falling out.” CHIEF COMPLAINT (CC): “I have been feeling tired and my hair is falling out”. HISTORY OF PRESENT ILLNESS (HPI): 32-year-old AA female presents with complaints of chronic fatigue, beginning approximately a year ago. Although the patient states that she is not depressed, she expresses the fatigue impacts her daily life making it difficult to work and care for her family. Associated symptoms include episodic alopecia, chronic insomnolence, weight-gain, and cold intolerance- accompany her chronic fatigue. The patient complains that most days she becomes increasingly fatigued in the afternoon, with no notable relief with periodic rest. Symptoms exacerbate with lack of sleep and anorexia. Although the patient is able to participate in some of her personal hobbies, she feels her symptoms are severe and that she is in desperate need of relief. PAST MEDICAL HISTORY: 1. Appendectomy at age 16 2. C-section of third child in 2016
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3 ALLERGIES: No Known Drug Allergy (NKDA) Peanut allergy commenced during childhood. Ingestion of peanuts initiates a hypersensitivity reaction resulting in urticaria and anaphylaxis. History includes 3 episodes with the use of an Epinephrine 0.3mg auto-injector. PAST MEDICAL HISTORY (PMH) Recently received a tetanus booster as a result of a laceration to her hand from a knife being used in the kitchen. The laceration healed without incidence. Patient states she was put on ‘Birth Control’ pills to improve menstrual cycle duration. History of Menorrhagia since the birth of her last child three years ago. Complained that her cycle would last for weeks and she would have bleeding most of the time. Patient states that she has had some relief with her birth control pills. MEDICATIONS: 1. Epinephrine Auto-injector 0.3mg IM PRN peanut allergy 2. Aranelle oral contraceptive 1qd for the past 2 years-without incidences. 3. Multi-vitamin 1qd 4. Ibuprofen 200mg Over the Counter 1-2 for headache or menstrual cramping; usually takes 1-2 doses per week SOCIAL HISTORY: Patient is an Administrative Assistant for a law firm. She enjoys spending time with her 3 children aged 3, 5 & 7. Patient states that she is a single mother. The patient stated that she, “Works on her stress level and attains exercise by walking her and attending kickboxing classes
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