Review the following case study.
In a Word file construct a subjective data set for the case from the information provided.
Structure the subjective data set in the format provided in your lecture materials.
NU610 Unit 3 Case Study
A 36-year-old female with a medical history of Multiple Sclerosis (MS) complains of constantly feeling
tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been on
Interferon. As a wife and mother of 2 with a full-time job, she states that by the end of the day, she has
no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a
few months back, but it has gotten progressively worse. She also mentions that she has missed several
days at work over the last 4 weeks because after getting showered and dressed, she had no energy left
to go to work. Reports occasional glass of wine on the weekends, denies tobacco or illicit drug use. She
has tried some CBD oil to help with energy without relief. Reports sleeping more than eight hours a
night while needing several naps throughout the day. She reports an uncomfortable buzzing sensation
traveling from the neck to the spine with what sounds like a Lhermitte’s sign. She denies loss of bowel
or bladder. She denies fever, chills, weight loss, or weight gain. She reports some nasal congestion but
contributes to allergies which she takes cetirizine 10 mg PO daily. Reports she is up to date on her pap
smear. She does a monthly self-breast exam, which she denies concerns about. She saw her dentist and
eye doctor within the last year and has no issues or concerns. Reports her mother, who is alive, has
diabetes and hypertension. Her father and siblings are also alive without any health issues. She has an
aunt on her mother’s side who also had MS and currently uses a wheelchair. She is alert and oriented to
person, place, time, and situation. Does not appear in acute distress, is well-developed, and is slightly
obese in the abdominal section. Skin is dry, warm, and intact. Normocephalic, neck supple, no
thyromegaly. PERRLA is about 4mm pupil size. Conjunctivae rim pale. Optic fundi examined revealed a
uniform red to pink color; the disk is pale pink, vessels emanate from the optic cup, and the fovea was
slightly darker. Retinal vessels are free from hemorrhages or exudates. Face symmetrical. No
lymphadenopathy. The oral mucosa is pink and moist. Heart rate bradycardic at 56 beats per minute
but regular without pauses or extra beats. Lungs diminished bilaterally but otherwise clear. Abdomen
soft, non-distended, bowel sounds normoactive in all four quadrants. No suprapubic or CVA tenderness.
Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand
movements, gait steady. Muscle tone inspected and palpated, free from fasciculation, tenderness, or
atrophy. Strength 5/5 in all extremities.
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