Chamberlain College of Nursing – NR602:Week1.SOAP: Solved and Graded A

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Soap K.F. 37 F, S. CC Well Exam, ongoing fatigue, stress, issues falling asleep and staying asleep, and financial concerns. HPI: K.F. presents today with complaints of ongoing fatigue, stress, a... nd financial concerns. Reports difficulties falling and staying asleep. She states being stressed and having to move in with her parents and currently shares a room with her two younger children. K.F. recently separated from her spouse and states there is an impending divorce. She also reports not having a menses since giving birth of her last child O – Symptoms started when she moved in with her parents
L –Generalized
D – Every night C – Has trouble falling asleep and staying asleep
A – Stress and sleeping in same room with two younger children, ongoing divorce
R- None 
T –Advil PM every night and drinks a glass of wine. Current Meds: Advil PM 200 mg/38 mg 1 CAP PO Nightly Allergies: No allergies PMHx: Denies medical history other than four pregnancies, three births, one pre-term. Had one miscarriage at 10 weeks when she was 16. Reports PCOS as a teenager and has irregular menses. Diagnosed with gestational diabetes with last birth and preeclampsia. Had two C-sections. 

 Social History: Currently going through a divorce and recently moved in with her parents. She was a 15 year smoker of 1PPD up until 18 months ago. She drinks 1 glass of wine a night. She does not routinely exercise. She often skips breakfast and lunch and eats a quick, often processed dinner. She is not currently sexually active and has been abstinent for the last 6 months. Family History: Mother has history of hypertension, hyperlipidemia, Type 2 DM, glaucoma and breast cancer at age 50 treated with lumpectomy. Father has history of hypertension, hyperlipidemia and MI with stenting 5 years ago. She has two siblings who are in good health. She has had other family members die of old age. CONSTITUTIONAL: No weight loss, fever, chills, (-) weakness, (-) fatigue. HEENT: Eyes: (-) visual loss, (-) decreased night vision, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations (-) BLLE edema. RESPIRATORY: (-) shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: No Burning on urination. tenderness to palpation in the super-pubic area NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O: V/S: Height: 160 cm, Weight: 67 kg. B/P: 140/76, HR: 82, T: 98.7, Resp: 16, SpO2: 97% [Show More]

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