NURS 6521 Week 5 Case Study

Week 5 Case Study Patient Information: K.N. Age : 44 Sex : F Race: S: CC: proptosis and fatigue HPI: K.N., a 44-year-old female, arrives for a thorough medical examination. She expresses discomfort with proptosis and weariness. She adds that her eyes started to bulge three weeks ago, impairing her eyesight. She claims that she has been unable to finish her daily duties since she started feeling exhaustion two weeks ago. In addition to a swollen neck, she takes atorvastatin to treat hyperlipidemia. She claims a weight increase but denies fever, headache, vomiting, and diarrhea. Current Medications: atorvastatin 20 mg once daily Allergies: NKDA PMHx: immunizations are up to date. Received tetanus vaccine 5/10/2021. History of hyperlipidemia SOC Hx: K.N. is a local elementary school educator. Her household includes her spouse and two children. She enjoys reading literature and traveling as pastimes. She confesses to using alcohol on occasion. Denies using cigarettes or illegal drugs. Family HX: History of hyperlipidemia and type 2 diabetes in the mother. Paternal: hypertension Her sibling is in excellent health. ROS: 3 • GENERAL: Reports weight gain and fatigue. Denies fever or chills. • HEENT: Eyes: Reports proptosis. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat • SKIN: Denies rash or itching. • CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. • RESPIRATORY: Denies shortness of breath, cough or sputum. • GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. Denies abdominal pain. • GENITOURINARY: Denies pain on urination. • NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. • MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness. HEMATOLOGIC: Denies anemia, bleeding or bruising. • LYMPHATICS: Reports enlarged nodes in the neck. No history of splenectomy. PSYCHIATRIC: Denies history of depression or anxiety. • ENDOCRINOLOGIC: Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia • ALLERGIES: Denies history of asthma, hives, eczema or rhinitis. O. Physical exam: • Vital signs: H 5’5”, W 88 kg, RR 16 HR 89 BP 128/78