Reference no: EM133481234

Problem

A 39-year-old Caucasian woman presents to the office for her annual exam. She has no gynecologic concerns; however, she does complain of fatigue (Generalized weakness) over the past six months. She complains of feeling cold and needing to dress warmly over the winter months. Her mother recently passed away, and she reports feeling sad. Assessment by the LPN reveals significant for constipation, for which she has tried increasing her fiber and water intake without improvement. She has gained 5 pounds since her exam one year ago although she reports a 'balanced diet' and regular exercise 3-4 times per day. Her medical history is significant for high cholesterol, which she has controlled with her diet. She had a normal well-woman examination and Pap with HPV test test 1 year ago. She occasionally drinks socially and denies tobacco or drug use. She is married and has children that are 13, 10 and 7.

On examination, her blood pressure is 110/78 mm Hg; her pulse is 56; her respiratory rate is 12/min. Her height is 5'2" and her weight is 192 lbs. On further examination, the LPN notes thinning hair and dryness of the skin, and under-eye puffiness.
Treatment is started for hypothyroidism and anemia with the woman returning in 2 months. Vitals on assessment were: B/P 120/80, pulse 72, respirations 16 and denies any lethargy or difficulty with being cold anymore since treatment.

What data from the PRESENT PROBLEM are RELEVANT and must be interpreted as clinically significant by the nurse?