Tired for a Year and Calling It Night Shift: A Comprehensive Health History of a 52-Year-Old Filipino American Nurse, With Her Explanatory Model Asked in Her Own Words
[Student Name]
University of Phoenix
NRP/531: Advanced Health Assessment I
Week 1 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Ms. D., a 52-year-old registered nurse who emigrated from the Philippines 24 years ago, came to our primary care clinic for the first time. She said she had "just been tired" and would not have come except that her daughter insisted. This paper presents her comprehensive history, noting where cultural understanding shaped what I asked and how I recorded it.
Identifying Data and Source
Ms. D. is a 52-year-old married woman, a registered nurse working 12-hour night shifts on a telemetry unit. She is the source of the history and appears reliable. She speaks English fluently and also speaks Tagalog at home.
Chief Concern
"I'm tired all the time. It's probably the night shift."
History of Present Illness
Ms. D. reports fatigue for about a year, gradually worsening. It is present on work and off days, not relieved by sleeping 9 to 10 hours on days off. She has gained about 5 kg over the year despite eating less. She feels cold when others are comfortable, her skin is dry and she has noticed hair thinning. She has had constipation for several months. She denies fever, night sweats, chest pain, shortness of breath, bleeding, depressed mood or loss of interest, although she describes feeling "heavy." Her menstrual periods stopped 18 months ago. She has not tried any treatment except a vitamin B complex from a pharmacy and a ginger tea her mother recommends.
Her Explanatory Model
Kleinman et al. (1978) proposed asking patients how they understand their illness, because the patient's explanatory model shapes what she reports, what she expects and whether she follows a plan. I asked Ms. D. their questions in plain words. She calls the problem "pagod," tiredness, and believes it is caused by years of night shifts and by "getting older." She thinks it started when she took on extra shifts after her husband's hours were cut. She considers it mild, "not a real illness," and something she should handle herself. She expected to be told to rest. Her greatest fear, which she said only when I asked directly, is that she has "something with the heart," because her mother died of heart failure at 60.
Her explanation was plausible, which is exactly why it deserved to be tested rather than accepted.
Cultural Humility in the Interview
The stance described by Tervalon and Murray-García (1998) asks the clinician to keep examining her own assumptions and to share power with the patient, instead of claiming to know a culture from a list of its traits. I did not assume what being Filipino means for Ms. D. Instead, I asked what matters to her. She values being strong for her family and not complaining, which she connects to her upbringing, and she worries that her colleagues will think she cannot keep up. Knowing this, I made clear that tiredness for a year is a symptom worth investigating, not a weakness.
Past Medical History
Gestational diabetes with her second pregnancy, resolved. No known hypertension, thyroid disease or heart disease. Hospitalizations: two births, 1998 and 2002. Surgeries: none. Immunizations: current, including annual influenza vaccine through work.
Medications and Allergies
Vitamin B complex daily, ginger tea. No prescription medications. No known drug allergies.
Family History
Mother died at 60 of heart failure; she also had "goiter." Father, 79, has type 2 diabetes and hypertension. Sister, 49, has hypothyroidism. Two children, 24 and 20, healthy.
Social History
Married, lives with husband and younger child. Works four 12-hour night shifts a week, occasionally five. Never smoked, drinks alcohol rarely, no drug use. Diet: rice-based meals, fish and vegetables, more fast food on work nights. Exercise: little, "no time." She sends money monthly to relatives in the Philippines and describes financial pressure.
Review of Systems
Constitutional: fatigue, weight gain, cold intolerance. Skin: dry skin, hair thinning. Eyes: no changes. Cardiovascular: no chest pain, palpitations or edema; she says her heart is "fine" but worries. Respiratory: no cough or dyspnea. Gastrointestinal: constipation. Genitourinary: amenorrhea for 18 months, no urinary symptoms. Musculoskeletal: mild muscle aches. Neurological: slowed thinking, "fog." Psychiatric: no depressed mood, some worry. Endocrine: as above. Sleep: sleeps 5 to 6 hours after night shifts, 9 to 10 on days off, snoring reported by husband.
How the History Shapes the Differential
The history moves the differential beyond night shift. Fatigue with weight gain, cold intolerance, dry skin, hair thinning, constipation and slowed thinking, together with a mother with goiter and a sister with hypothyroidism, point strongly to hypothyroidism. Because these symptoms are common and nonspecific, the diagnosis rests on laboratory testing, with thyroid-stimulating hormone as the first test (Jonklaas et al., 2014), but the history is what makes the test worth ordering and interpreting. Other possibilities include shift work sleep disorder, obstructive sleep apnea given snoring and weight gain, depression, anemia, diabetes given her history of gestational diabetes and her father's diabetes and menopausal changes. Her fear about her heart deserves a response: hypothyroidism can affect the heart, and her family history makes cardiovascular risk assessment appropriate.
What I Almost Missed
Two parts of the history nearly went unrecorded. Ms. D. mentioned her mother's goiter only when I asked about each relative's conditions one by one, not when I asked the open question about family illnesses. And she mentioned the ginger tea only when I asked about anything she takes "from home or the store," not about medications. Both details matter: the family thyroid history raises the probability of thyroid disease, and herbal products can interact with prescriptions. The lesson is that open questions start a history but specific prompts complete it.
Developmental Considerations
At 52, Ms. D. is in midlife, often a period of caring for both children and aging parents while working full time. Her amenorrhea for 18 months places her in the menopausal transition, which can itself cause fatigue and sleep disruption and which must be separated from thyroid disease. Midlife is also when screening for diabetes, lipid disorders and cancers becomes routine, so her comprehensive visit is an opportunity to update preventive care.
Plan Shaped by the History
The physical examination will include thyroid palpation, skin and hair, reflexes with attention to delayed relaxation, weight and blood pressure. Laboratory tests will include thyroid-stimulating hormone, complete blood count, metabolic panel, A1C and lipids. A sleep apnea screening questionnaire will be completed. I told her that her tiredness has likely causes that can be found and treated, and that we would check her heart risk as well, which visibly relieved her.
Conclusion
A comprehensive history turned "just tired from night shift" into a pattern pointing to hypothyroidism, with sleep apnea, diabetes and other causes to rule out. Asking Kleinman's explanatory model questions revealed her understanding and her unspoken fear, and an approach of cultural humility allowed her to accept that her symptom was worth investigating. The history, not the tests, set the direction for everything that followed.
References
Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., Cooper, D. S., Kim, B. W., Peeters, R. P., Rosenthal, M. S., & Sawka, A. M. (2014). Guidelines for the treatment of hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid, 24(12), 1670-1751. https://doi.org/10.1089/thy.2014.0028
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258. https://doi.org/10.7326/0003-4819-88-2-251
Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. https://doi.org/10.1353/hpu.2010.0233
How this NRP 531 Week 1 example is structured
The NRP/531 Week 1 work usually asks students to document a comprehensive history with attention to culture and development. This paper presents the history in standard order, explains the purpose of each section and shows where the patient's own understanding of her illness changed what was asked and recorded. Students search this week as NRP 531 Week 1, NRP531 Wk 1 or NRP/531 Wk 1; all three are the same assignment.
NRP/531 Week 1 questions, answered
What does NRP/531 Week 1 usually ask for?
Many sections ask students to take and document a comprehensive health history, including cultural and developmental considerations, and to explain how it guides assessment.
What are Kleinman's explanatory model questions?
A set of questions asking what the patient calls the problem, what caused it, why it started when it did, how severe it is, what treatment she expects and what she fears most, so the clinician understands the illness from the patient's view.
What is cultural humility?
A lifelong practice of self-reflection and learning in which the clinician recognizes the limits of her knowledge of another's culture and treats the patient as the expert on her own experience.
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