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NR603 week1 Soap Chamberlain College of Nursing
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  • NR603
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  • Chamberlain College Of Nursing

NR603 week1 Soap Chamberlain College of Nursing Ed, 19yr M. S: CC: “Not feeling well”, Fatigue. HPI: This is a 19yr old second semester college student, who comes into the clinic with complaint of fatigue for the past 2 months. He reports difficulty getting up for class, feeling down and...

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  • July 8, 2022
  • 11
  • 2021/2022
  • Exam (elaborations)
  • Questions & answers

Subjects

  • nr603 week1 soap chamberlain college of nursing ed
  • 19yr m s cc “not feeling well”
  • fatigue hpi this is a 19yr old second semester college student
  • who comes into the clinic with complaint of f

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  • Chamberlain College Of Nursing
  • NR603
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NR603 week1 Soap Chamberlain College of
Nursing

Ed, 19yr M.

S:

CC: “Not feeling well”, Fatigue.

HPI: This is a 19yr old second semester college student, who comes into the clinic with

complaint of fatigue for the past 2 months. He reports difficulty getting up for class,

feeling down and is not doing well in his courses. He reports that he doesn’t enjoy the

activities that he used to. He reports that he goes out at night with friends but have no

energy to get up in the morning anymore. Ed reports being in general good health and

denies any health conditions. He denies using any medication currently.

OLDCART/ROS

When did you start feeling fatigue? (2 months ago)

How often does it occur? ongoing

What does it feel like? difficulty getting up for class, feeling down and is not doing well

in his courses. Does not enjoy the activities that he used to

What factors makes your fatigue worse? goes out at night with friends but have no

energy to get up in the morning anymore.

What factors improve your fatigue? none

How severe are your symptoms? Drinking alcohol three to four times per week and

coming home after 2 am on those nights. He sleeps 4 to 6 hours a night at this time.

Do you experience blurred vision, headaches? Have you had any recent weight loss?

Nausea, vomiting, diarrhea?

Do you experience shortness of breath with minimal or moderate exertion at rest,

walking, eating, or talking?. Do you have any history or family history of cardiac

, problems, respiratory disease, asthma, emphysema, COPD? Have been exposed to

occupational or any environmental or chemical exposure? How often do you smoke, how

many pack per day? When did you start smoking? When did you start drinking? How

much do you drink? Have you had problems at school, at work or in your relationships

that may be related to alcohol use? Have there been times that you behaved in a

dangerous, harmful or violent way when you were drinking? Do you have any physical

health problems, such as liver disease or diabetes? Do you use recreational drugs?Any

family hx of depression, suicide, alcohol abuse? Do you think you are depressed?

PMH: hay fever, broken leg requiring traction at age

8. Allergies: NKDA;

Medication: None

Immunizations: UTD

Social History: Single full-time college student. Unemployed.

He smokes cigarettes—a pack a day. He reports drinking alcohol three to four times per

week and coming home after 2 am on those nights. He sleeps 4 to 6 hours a night at this

time.

Family: Reports parents and siblings alive and in good

CONSTITUTIONAL: -fever. - chills.

HEENT: - Dizziness, - headaches, - changes in vision, - ear pain, -nasal drainage, - sore

throat.

CARDIOVASCULAR: - chest pain, - palpations, - edema lower extremities.

RESPIRATORY: - shortness of breath on exertion, - productive cough with white

sputum,

-cough hemoptysis.

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