Evans. Week7.soap - Patient Katie CC No energy HPI Had pneumonia a month ago and havent gotten energy back I just dont feel like doing anything now Its

Evans. Week7.soap - Patient Katie CC No energy HPI Had...

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Patient: Katie CC: No energy. HPI: “Had pneumonia a month ago and haven’t gotten energy back. I just don’t feel like doing anything now.” “It’s hard to get up and get moving in the morning and I don’t sleep very well now.” “I keep waking up about 4 AM every day and I can’t get back to sleep.” “I try to go back to sleep but then I start thinking about all the things I need to do and being so tired and wanting to go back to sleep and then I can’t get back to sleep.” Does not feel like doing much of anything. Her ADLs are hard to do. She doesn’t want to go out with friends, exercise or even go to church. She doesn’t have an appetite. Just feels really blah.” Current Medications : Multivitamin, Evista 60 mg daily and HCTZ 25 mg daily Allergies: NKDA, has seasonal allergies to pollen and reports hay fever in the fall PMHx: Had chicken pox, measles and rubella as a child. Katie has a history of osteopenia, HTN and hyperlipidemia. Previous surgeries include a tonsillectomy and cholecystectomy. Hospitalized for surgeries and childbirth. Up to date on vaccines. Received the pneumonia vaccine last week. Fam Hx: Her parents died of old age. Siblings are well with same HTN problems she has. Social Hx: Married to John for 45 years, they live with married daughter and her family. Takes care of the kids and home as Mary and her husband work. Her husband and son both smoke but not in the house.
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