Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido

Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido

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Patient Information:

B.L., 54 years, Female, Not provided in the case study


CC (chief complaint): The patient presents with complaints of fatigue, night sweats, and low libido.

HPI: B.L., a 54-year-old female, reports experiencing fatigue, night sweats, and low libido. These symptoms have been ongoing, and the patient denies any recent changes in these complaints. The onset of these symptoms is not clearly specified in the case study. The character of fatigue is described as a generalized feeling of low energy. The night sweats and low libido are not further characterized. Associated symptoms include no information on nausea or vomiting. The timing of symptoms is not explicitly mentioned, and exacerbating or relieving factors are not provided. Severity of symptoms is not quantified. Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido


Current Medications: The patient denies taking any hormones or other medications. However, based on the clinical assessment, it is recommended to initiate Premarin 0.3 mg PO daily.

Allergies: No information on allergies is provided in the case study.

PMHx: The patient had a partial hysterectomy at age 40 due to uterine prolapse. The case study does not mention other major illnesses or immunization status.

Soc & Substance Hx: B.L. is a non-smoker with a history of two c-section deliveries. No information is provided about her occupation, major hobbies, or family status. The patient denies using any medications or hormones. Health promotion questions, such as seat belt use or smoke detector status, are not addressed in the case study.

Fam Hx: No information on family history.

Surgical Hx: The patient had a partial hysterectomy at age 40 due to uterine prolapse.

Mental Hx: No information on the patient’s mental health, diagnosis, or treatment is provided in the case study.

Violence Hx: No information provided about the patient’s safety concerns, personal, home, community, sexual, or historical.

Reproductive Hx: B.L. had a partial hysterectomy at age 40 and, therefore, has no menstrual history or current contraceptive use. The case study does not provide information on sexual activity, sexual preferences, or any specific sexual concerns. Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido


GENERAL: The patient reports fatigue and night sweats but denies any weight changes, fever, or chills.

HEENT: No complaints related to the head, eyes, ears, nose, or throat.

SKIN: No reported skin changes, lesions, or abnormalities.

CARDIOVASCULAR: No chest pain, palpitations, or edema. No history of cardiovascular issues mentioned.

RESPIRATORY: No shortness of breath, cough, or respiratory symptoms reported.

GASTROINTESTINAL: No abdominal pain, nausea, vomiting, diarrhea, or constipation mentioned.

NEUROLOGICAL: No headaches, dizziness, numbness, or other neurological symptoms reported.

MUSCULOSKELETAL: No joint pain, muscle pain, or limitations in mobility reported.

HEMATOLOGIC: No history of bleeding disorders or easy bruising reported.

LYMPHATICS: No swollen glands, tenderness, or history of lymphatic issues mentioned.

PSYCHIATRIC: No complaints related to mood, anxiety, or cognitive function reported.

ENDOCRINOLOGIC: Menopausal symptoms, including low libido, are mentioned. No other specific endocrine-related symptoms reported.

GENITOURINARY: History of partial hysterectomy at age 40 due to uterine prolapse. Low libido reported. No urinary symptoms mentioned. Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido

ALLERGIES: No known allergies reported.


Physical exam:

General: The patient appears fatigued, with no acute distress. Skin color is normal.


Head: Normocephalic, atraumatic.

Eyes: Pupils equal, round, and reactive to light. No scleral icterus or conjunctival pallor.

Ears: No signs of infection or discharge.

Nose: No nasal congestion or discharge.

Throat: Mucous membranes moist, no erythema or exudate.

Cardiovascular: Regular heart rate, no gallops or murmurs. Radial pulses are equal bilaterally.

Respiratory: Lungs clear to auscultation bilaterally, no wheezing or crackles.


Abdominal exam reveals a healed surgical scar consistent with a previous C-section.

Pelvic exam not conducted as it is not indicated for the chief complaint and HPI.


Oriented to person, place, and time. Cranial nerves intact.

No focal neurological deficits observed. Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido


Diagnostic results:

  1. Mammogram:

Findings: Pending results.

Clinical Interpretation: Mammograms are essential for breast cancer screening, particularly in women over 50 years old. Abnormal findings, such as masses or microcalcifications, could indicate the need for further investigation or biopsy.

  1. Wellness Labs:

Comprehensive Metabolic Panel (CMP):

  1. Electrolytes: Within normal limits.
  2. Blood glucose: Within normal limits.
  • Liver function tests (AST, ALT, ALP): Within normal limits.
  1. Kidney function tests (BUN, creatinine): Within normal limits.
  2. Albumin: Within normal limits.
  3. Total protein: Within normal limits.

Complete Blood Count (CBC):

  1. White Blood Cell (WBC) count: Within normal limits.
  2. Hemoglobin: Within normal limits.
  • Hematocrit: Within normal limits.
  1. Platelet count: Within normal limits.
  2. Red Blood Cell (RBC) indices: Within normal limits.

Clinical Interpretation: The wellness labs provide a baseline assessment of the patient’s metabolic and hematologic status, ruling out any immediate concerns. Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido

  1. FSH (Follicle-Stimulating Hormone) Level:

Result: Pending.

Clinical Interpretation: FSH levels are crucial to confirm the patient’s menopausal status. Elevated FSH levels are indicative of reduced ovarian function and support the diagnosis of menopause.

  1. Lipid Panel:
  1. Total Cholesterol: Pending.
  2. LDL (Low-Density Lipoprotein) cholesterol: Pending.
  • HDL (High-Density Lipoprotein) cholesterol: Pending.
  1. Triglycerides: Pending.

Clinical Interpretation: Assessing lipid levels is essential to evaluate cardiovascular risk, especially in postmenopausal women. Abnormal lipid profiles may necessitate lifestyle modifications or pharmacological intervention.


Primary and Differential Diagnoses

Primary Diagnosis:

Menopause: The patient, a 54-year-old female, presents with classic menopausal symptoms, including fatigue, night sweats, and low libido. Her age aligns with the typical onset of menopausal symptoms. A history of partial hysterectomy at age 40 supports the likelihood of menopause. The absence of hormone replacement therapy (HRT) and the recommendation of Premarin are consistent with managing menopausal symptoms (Davis & Baber, 2022)Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido.

Differential Diagnosis:

  1. Hypothyroidism: Limeres et al. (2021) state that fatigue is a common sign of hypothyroidism. The patient reports fatigue, thus it is vital to assess thyroid function. Menopausal symptoms can occasionally occur with thyroid dysfunction. This needs to be ruled out. Thyroid function testing is advised by the American Thyroid Association when evaluating fatigue and other non-specific complaints.
  2. Depressive Disorder: According to Lu et al. (2021), changes in libido and fatigue may also be linked to depressive disorders. Based on the patient’s symptoms, a thorough mental health evaluation is necessary. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria of the American Psychiatric Association can be used to guide the evaluation of depressive disorders.
  3. Cardiovascular Disease: Cardiovascular problems may be linked to fatigue, particularly when overt menopausal symptoms are absent. Evaluating cardiovascular risk is necessary, especially considering the patient’s age. Lipid panel testing is advised for the assessment of cardiovascular risk in people between the ages of 40 and 75 by the American College of Cardiology and the American Heart Association (Lawton et al., 2022)Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido.

Primary Diagnosis: Menopause

Diagnostic Studies:

  1. Pending FSH levels to confirm menopausal status.
  2. Recommend a repeat mammogram for breast cancer screening due to the lapse in time since the last one.

Therapeutic Interventions: Initiate Premarin 0.3 mg PO daily for menopausal symptom management.


  1. Educate the patient on Premarin benefits and potential risks.
  2. Emphasize the importance of regular mammograms for breast health.

Disposition and Follow-Up:

  1. Schedule a 1-month follow-up to assess Premarin response and symptoms.
  2. Await FSH level and mammogram results for further management decisions.

Differential Diagnoses: Hypothyroidism, Depressive Disorder, Cardiovascular Disease

Diagnostic Studies and Referrals:

  1. Order thyroid function tests (TFTs) to rule out hypothyroidism.
  2. Consider mental health assessment or psychiatrist referral for depressive symptoms.
  3. Conduct a lipid panel for cardiovascular risk assessment.
  4. If urogenital atrophy is suspected, consider a pelvic exam or gynecologist referral.

Therapeutic Interventions: Tailor interventions based on diagnostic findings.

Education: Emphasize regular thyroid function testing, mental health awareness, and cardiovascular risk factors.

Disposition and Follow-Up:

  1. Schedule follow-ups based on diagnostic findings.
  2. Coordinate with specialists for additional conditions.


I support the preceptor’s management strategy for menopausal symptoms and starting Premarin. The diagnostic studies are in line with evidence-based guidelines for women going through menopause. The plan emphasizes the value of regular exams like lipid panels and mammograms. Reflecting on this case, I have a better understanding of the complex nature of patient complaints and the necessity of a comprehensive approach.

In terms of health promotion and disease prevention it is imperative to consider the patient’s age and gender. Emphasizing routine screenings and addressing risk factors for cardiovascular disease aligns with preventive care. Tailored education and interventions are informed by understanding patient factors like cultural background and socioeconomic status. Moving forward, I would continue to integrate a holistic approach in patient care. Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido


Davis, S. R., & Baber, R. J. (2022). Treating menopause—MHT and beyond. Nature Reviews Endocrinology, 18(8), 490-502.

Lawton, J. S., Tamis-Holland, J. E., Bangalore, S., Bates, E. R., Beckie, T. M., Bischoff, J. M., … & Zwischenberger, B. A. (2022). 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation145(3), e4-e17.

Limeres, P. C., Cruz, B. D. L. T., Del Campo, A. C., & Soler, A. F. (2021). Depression and hypothyroidism: Literature review and case report. European Psychiatry64(S1), S329-S329.

Lu, J., Xu, X., Huang, Y., Li, T., Ma, C., Xu, G., … & Zhang, N. (2021). Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological study. The Lancet Psychiatry8(11), 981-990.

For this assignment, you will select a patient with a common gynecologic health condition from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient. Patient info below. Fill in the blanks where needed in the template.  NEED AT LEAST 3 SCHOLARLY REFERENCES APA FORMAT

  • Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment. ATTACHED Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido


  • Subjective: What details did the patient provide regarding her personal and medical history?
  • Objective: What observations did you make during the physical assessment?
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? Please do not just list diagnoses with definitions. This MUST be a working list of differential diagnoses so that I can see your thought processes and how you decided on the primary diagnosis.
  • Plan: What was your ACTUAL plan for diagnostics and primary diagnosis? What was your ACTUAL plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationalefor this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation? If your plan of care was done in a manner that your research showed a better alternative, please list this here and why you would change the plan of care in the future.  Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido

I am looking for SOAP notes that show me your knowledge and ability to care for a patient with this diagnostic concern. 


Class Resources

  • Weston, C., Page, R., Jones-Schubart, K., & Akinlotan, M. (2018). Improving cancer screening for underserved women through an FNP student-led clinicLinks to an external site.. The Journal for Nurse Practitioners, 14(5), e101–e104.

Practicum Resources 

  • Walden University Field Experience. (n.d.-a).Field experience: College of Nursing.Links to an external site.
  • Walden University Field Experience. (n.d.-b). MSN nurse practitioner practicum manual.Links to an external site.
  • Walden University Field Experience. (n.d.-c). Student practicum resources: NP student orientation.Links to an external site.
  • HSoft Corporation. (n.d.). MeditrekLinks to an external site..
    Note:Use this website to log in to Meditrek to report your clinical hours and patient encounters.
  • Document:Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document) Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido


Clinical Guideline Resources 

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).

  • American Cancer Society.Links to an external site.(n.d.).
  • American College of Obstetricians and Gynecologists.Links to an external site.(n.d.).
  • Centers for Disease Control and Prevention.Links to an external site.(n.d.). Links to an external site.
  • ANA Enterprise.Links to an external site.(n.d.).
  • HealthyPeople 2030. (2020).Healthy People 2030 framework.Links to an external site. to an external site.
  • The American Association of Nurse Practitioners.Links to an external site.(2020).
  • S. Preventive Services Task ForceLinks to an external site.. (n.d.-a). Case Study For Patient Complaining Of Fatigue, Night Sweats, And Low Libido

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