1
NU610 Unit 3 Case Studies
Student Name
University
Course
Professor Name
Date
, 2
NU610 Unit 3 Case Studies
Case 1
Subjective (S):
CC: A 36-year-old female is constantly feeling tired even after a period of rest or sleep; no
energy by the end of the day. She began noticing her tiredness and lack of energy a few months
back, but it has gotten progressively worse. The patient also mentions that she has missed several
days at work over the last 4 weeks because she had no energy left to go to work after getting
showered and dressed.
HPI: O=onset: Multiple Sclerosis (MS). L=location: Spinal cord. D=Duration: 3 years.
C=characteristics: Lhermitte's sign. A=associated/aggravating factors: Work. R=relieving
factors: CBD oil. T=treatment: Interferon. S=Summary: Multiple Sclerosis (MS), no energy.
PMH: Been diagnosed with Multiple Sclerosis (MS) 3 years ago.
Allergies: Nasal congestion; takes cetirizine 10 mg PO daily.
Medication: Interferon, cetirizine.
Social History: Reports occasional glass of wine on the weekends, denies tobacco use or illicit
drug use.
Family History: Maternal. The patient is a wife and mother of two who is working full-time. She
has an aunt with MS on her mother's side who uses a wheelchair. She has a mother who is
diagnosed with diabetes and hypertension. Her father and siblings are alive with no health issues.
Health Maintenance/Promotion: She tried CBD oil to aid with energy, but it was ineffective.
Sleeps more than eight hours per night and requires several naps during the day. She has a
current pap smear, does a monthly self-breast assessment, and denies any issues on the exam.
ROS: A 36-year-old female. The patient does not seem to be in severe discomfort, is well-
NU610 Unit 3 Case Studies
Student Name
University
Course
Professor Name
Date
, 2
NU610 Unit 3 Case Studies
Case 1
Subjective (S):
CC: A 36-year-old female is constantly feeling tired even after a period of rest or sleep; no
energy by the end of the day. She began noticing her tiredness and lack of energy a few months
back, but it has gotten progressively worse. The patient also mentions that she has missed several
days at work over the last 4 weeks because she had no energy left to go to work after getting
showered and dressed.
HPI: O=onset: Multiple Sclerosis (MS). L=location: Spinal cord. D=Duration: 3 years.
C=characteristics: Lhermitte's sign. A=associated/aggravating factors: Work. R=relieving
factors: CBD oil. T=treatment: Interferon. S=Summary: Multiple Sclerosis (MS), no energy.
PMH: Been diagnosed with Multiple Sclerosis (MS) 3 years ago.
Allergies: Nasal congestion; takes cetirizine 10 mg PO daily.
Medication: Interferon, cetirizine.
Social History: Reports occasional glass of wine on the weekends, denies tobacco use or illicit
drug use.
Family History: Maternal. The patient is a wife and mother of two who is working full-time. She
has an aunt with MS on her mother's side who uses a wheelchair. She has a mother who is
diagnosed with diabetes and hypertension. Her father and siblings are alive with no health issues.
Health Maintenance/Promotion: She tried CBD oil to aid with energy, but it was ineffective.
Sleeps more than eight hours per night and requires several naps during the day. She has a
current pap smear, does a monthly self-breast assessment, and denies any issues on the exam.
ROS: A 36-year-old female. The patient does not seem to be in severe discomfort, is well-
