SU_NSG6420_W10_A4_Taylor_A.doc - SOAP NOTE Name TJ Date Age 25 Time 10:30 Sex F SUBJECTIVE CC \u201cTired all the time\u201d HPI 25-year-old Caucasian female

SU_NSG6420_W10_A4_Taylor_A.doc - SOAP NOTE Name TJ Date Age...

This preview shows page 1 - 2 out of 4 pages.

SOAP NOTE Name: TJ Date: 1/10/19 Time: 10:30 Age: 25 Sex: F SUBJECTIVE CC: “Tired all the time” HPI: 25-year-old Caucasian female complaining of increasing fatigue over about 6 months. State she feels tired all day, decreased interest in usual activities, less able to complete routine tasks, and generally slowed up. Sleeping more than previously 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 particular concern. Medications: Multi-Vitamin – general health Tylenol – OTC for occasional aches and pains Metamucil – for occasional constipation PMH Allergies: NKDA Hospitalization for childbirth x3. G3P3 LC3. Unsure of immunization status. No recent influenza, tetanus. Last physical/pelvic/Pap about 3 years ago. No other screening. Does not do BSE. Contraception by husband's vasectomy.
Image of page 1
Image of page 2

You've reached the end of your free preview.

Want to read all 4 pages?

  • Summer '16
  • ANDREWCLARK
  • throat pain

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture