Name: S.S Date: Time: 12:30 p.m
  Age: 68 Sex: Female

My skin is turning pale, and my feet and hands are cold. I’m also exhausted.”



S.S. complains of her skin turning pale and feeling cold in her feet and hands when she visits the clinic. The patient claims that she has been experiencing these symptoms for three weeks. She says the icy sensation in her feet and hands is accompanied by headaches, chest pain, and dizziness, all of which subside after taking ibuprofen. She also claims that she is unable to walk long distances because she is out of breath and weak, in addition to being exhausted. She takes frequent breaks to gather her breath. She also mentions that, despite being a vegetarian, she has had an inclination to eat dirt. Since being diagnosed with positive HBV, the patient reports she has been avoiding meals. Pylori.

She denies blood in stool, states that the last colonoscopy was in 2010 with normal results.

Medications: Ibuprofen PRN for headache and chest pain Levothyroxine 0.50 mcg/daily for hypothyroidism
PMH: Hypothyroidism diagnosed in 2013

Allergies: NKD

Medication Intolerances: None


She mentions that in 2009, she underwent a breast biopsy for suspected breast cancer, but the results were negative. Colonoscopy 2010 negative results.

Family History

Father died 20 years ago from coronary artery disease. Mother died 15 years ago from diabetes. Brother was diagnosed with colon cancer 2 years ago. Other siblings are healthy.

Social History

Patient holds a Bachelor’s degree in commerce. Patient worked as a bank manager before retiring. Patient is married and lives with her husband (74 years of age) and two grandchildren (19 years and 15 years of age). Patient does not consume alcohol, smoke or abuse drugs. Patient mentions putting on her seatbelt on always.


Patient reports feeling extremely fatigued, dizzy, and feeling weak. Denies, night sweats, fever, chills, weight change


Patient reports dyspnea and chest pain. Denies edema


Patient reports pale skin. Denies bruising,


Patient reports dyspnea and wheezing. Denies


rashes, or lesions cough, hemoptysis, hx of pneumonia or TB

Patient wears corrective lenses, reports blurring vision


Denies abdominal pain, diarrhea, vomiting, nausea, or changes in stool color or bowel movement


Denies discharge, hearing loss, ear pain, ringing in ears


Denies burning, changes in color of urine, urgency, or frequency or vaginal discharge


Denies nose bleeds or discharge, dental disease, sinus problems, dysphagia, throat pain, hoarseness,


Denies joint swelling, back pain, fracture hx, pain or stiffness, osteoporosis


Denies SBE, bumps, tumors, or changes


Reports feeling weak. Denies paresthesia, syncope, black out spells, transient paralysis, seizures


Denies hx of blood transfusion, bruising, swollen glands, cold or heat intolerance, night sweats, increase hunger or thirst


Patient reports being anxious. Denies sleeping difficulties, depression, suicidal attempts/ideation

Weight 130 lbs. BMI 21.0 Temp 98.0 BP 123/62
Height 5’6 Pulse 105 Resp 17
General Appearance

Well-nourished and well-developed, normal asthenic. Excellent attention to grooming


Skin is pale. Clear to lesion, rashes or ulcers


Head is normocephalic/atraumatic without lesions; hair consistently dispersed. Eyes: PERRLA. Scleral injection or Conjunctival absent. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Canals patent. Nose: Normal turbinate’s; nasal mucosa pink. Septal deviation absent. Neck: Supple. Full ROM; cervical lymphadenopathy and occipital nodes absent. Nodules or thyromegaly absent.

Oral mucosa moist and pink. Non erythematous pharynx without exudate. Teeth are in excellent repair.


Regular RR. Gallops and rubs absent. JVD absent. 2+ peripheral pulses in both dorsalis and both radialis bilaterally


Lungs clear to auscultation and percussion

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