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Running head: WEEK 5: SUMMARY1Week 5: APEA Case Presentation SummaryChamberlain UniversityNR603: Advanced Clinical Diagnosis and Practice Across LifespanMarch 2018SOAP Week 5Patient Information:A.L., 38-year-old female, Caucasian, insurance unknown. (S) Subjective: CC:"tired all the time"HPI: 38-year-old white woman complaining of increasing fatigue over about 4 months. Feels tired all day,decreased interest in usual activities, less able to complete routine tasks, and generally slowed up. Sleeping more than previously (now approximately 9 pm to 7:30 am) but does not feel rested. Does not wake during night or nap during day. No recent acute illnesses. No precipitating events for fatigue. Family, friends and co-workers are criticizing her for low performance of usual activities and negative attitude. Is not aware of other major symptoms. Is concerned "something is wrong" but can't specify a concern.Current Medications:Denies prescription medication. Takes daily multivitamin for last month. No regular use of OTC, herbal or other supplements. Tylenol @ 1-4 per month for shoulder/neck pains or headaches. Recently tried Metamucil for constipation.Allergies: NKDA.
WEEK 5: SUMMARY2PMHx: Denies past medical history.PSHx: Denies past surgeries. Hospitalization for childbirth x3. G3P3 LC3. Childhood Illnesses: None reported.Immunization Hx: Unsure of immunization status. No recent influenza, tetanus.Other Screenings: Last physical/pelvic/Pap about 3 years ago. No other screening. Does not do BSE. Contraception by husband's vasectomy.Soc Hx:Smoked ½ ppd from age 16-22. Drinks <2 glasses wine/month, no use of illicit substancesPart-time teacher's aide in special education class (3 mornings per week). Currently not doing well at work, can't keep up with the stress.