Week 10 SOAP Note - Mary Jones

Week 10 SOAP Note - Mary Jones Week 10- SOAP Note Identifying data Name: Mary Jones Age: 40-year old Gender: Female S) CC: Fatigue HPI: Mary presents to the clinic after 2-months since being treated for an ectopic pregnancy. Today, she arrives at the clinic with her head bowed down, looking pale and slightly unkept. Mary shares that “Tom insisted that she [I] come see me [you].” She then reports of progressively worsening fatigue, difficulty getting up in the morning and doing her regular house chores. She goes on to report that she tires easily and does not have the energy to do anything else at home. She reports trying to go to bed early but being awake till about 3-4am. She tends to only get about 2-3 hours of sleep a night. Mary says that at times, she lies awake at night and sleeps most of the day. Mary also shares that “Tom does not even think about the lost pregnancy [it]. Since then, Mary and Tom have been having problems being intimate because she has lost interest; the same way she has lost interest in a lot of things. Mary refused to see the clinic behavioralist and she felt that she is closer to me.