NR603 Week 5 Case Summary.docx - Running head WEEK 5 SUMMARY 1 Week 5 APEA Case Presentation Summary Chamberlain University NR603 Advanced Clinical

NR603 Week 5 Case Summary.docx - Running head WEEK 5...

This preview shows page 1 - 3 out of 6 pages.

Running head: WEEK 5: SUMMARY 1 Week 5: APEA Case Presentation Summary Chamberlain University NR603: Advanced Clinical Diagnosis and Practice Across Lifespan March 2018 SOAP Week 5 Patient 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: SUMMARY 2 PMHx : 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 substances Part-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.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture