NR603 Week 7 Soap

L, 44 F, S. CC: “fatigue x3 weeks” HPI: This is a 40 year old female who comes to the clinic for complain of fatigue. She reports an onset of about 3 weeks with flu-like symptoms. She reports tinge to skin color, decreased appetite, nausea, muscle aches and stomach cramps. She also said she has lost 5 pounds. She admits that she recently got a tattoo. Laura said she has been divorced for 2 years, dating for 1 year. She is sexually active with 2 partners in the last 6 months and does not use condoms. Laura reports that she is taking Ibuprofen for the aches and pains but no other OTC medications. PMHx: Good health. Exercises regularly. Chronic illness: none Surgeries: cholecystectomy, total abdominal hysterectomy Hospitalizations: childbirth x 2 Blood transfusions: None Immunizations: does not get flu shot. Allergies: Penicillin (rash) Current Meds: daily multivitamin, fish oil, and CoQ 10; Ibuprofen PRN pain, aches. Social Hx: None ETOH, tobacco, illicit drugs. She drinks alcohol socially, does not smoke, denies illicit drug use. Sleeps 6 to 8 hours per night. Divorced for 2 years, dating for 1 year. Sexually active with 2 partners in the last 6 months. Does not use condoms, had a BTL (Bilateral tubal ligation) 10 years ago. Family: Parents are alive in good health. She has 2 daughters in good health. OLDCART • O: Onset: When did you begin to experience fatigue? Did the symptoms come on suddenly? • L: Location: Tell me about your fatigue, is this generalized? • D: Duration: “Are your symptoms continuous or intermittent”? what time of the day do you feel it most? • C: Characteristics/Associated Symptoms: been nauseous, decreased appetite and nausea , lost 5 pounds, muscle aches and has stomach cramps, Do you have loss of interest in doing the things you like? Any fever? Dizziness? Any vomiting? If yes, how often is the vomiting, what color? • A: Aggravating: “Does anything make your symptoms worse? Any difficulty controlling your urine? How often do you wake up at night to urinate? Any blood in your urine?, any previous diagnosis of urinary tract infection? Any history of anorexia, depression, diabetes, cancer, in the family? R: Relieving Factors: Does anything make your symptoms better? T: Treatments: Have you used any medication or other OTC or prescription medications for your symptoms? • S: Severity: “skin color has a funny tinge to it.” ROS General: (+) Malaise, (+) Weight loss, (+) Fever, (+) Lack of appetite, (+)Fatigue. Skin: (-) Uticaria , (-) Pruritus, (-) lesions, (-) erythema, (+) Jaundice Cardiopulmonary: (-) Palpitations (-) dyspnea, (-) chest pain Abdomen: (+) Pain, (-) tenderness, (-) distension. GI: (+) Nausea, (-) vomiting, (-) diarrhea, (-) bloody stool (-) constipation. GU: (-) Dark-colored urine, (-) Hematuria, (-) Dysuria, (-) frequency Hematology: (-) bruising, (-) ecchymosis Lymphatic: (-) lymphadenopathy, (-) swelling, (-) tenderness O: P. E: VS : Ht 5’9”, Wt 150lbs, BP 126/76, T 98.0, P 72, R 12. Labs: HbsAg- negative, HbsAb- positive, HbcAb –positive, Amylase- normal, Lipasenormal, ALT- Normal, AST- Normal. General: Well-dressed, appears stated age, and in no apparent distress. Alert, oriented and cooperative. Skin: Warm, dry, and intact. Skin color is slightly jaundiced. No moles noted. No track marks noted. HEENT: Normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: icteric, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nose: Nares patent without exudate. Sinuses nontender to palpation. Throat: Oropharynx moist, no lesions or exudate. Tonsils 1/4 bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small, and firm w/o masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Recent tattoo noted to lower back. CV: Heart S1, S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally. Abdomen: Round, soft, w/ BS all 4 quadrants. No organomegaly noted. Mild tenderness in RUQ. No CVAT. A: Assessment: Acute hepatitis B (B16) ICD 10is a serious liver infection caused by the hepatitis B virus (HBV). It is usually transmitted through sex, sharing needles, dirty needle sticks etc. (Nebbia, Peppa, & Maini, 2012). Acute hepatitis B infection lasts less than six months as most adult’s immune system likely can clear acute hepatitis B from the body, and they can recover completely within a few months (Nebbia, Peppa, & Maini, 2012). Having chronic hepatitis B increases the risk of developing liver failure, liver cancer or cirrhosis. Symptoms of acute hepatitis usually appear about one to four months after exposure, which includes: abdominal pain, dark urine, fever, joint pain, loss of appetite, nausea and vomiting, weakness and fatigue, yellowing of your skin and the whites of the eyes (jaundice) (Nebbia, Peppa, & Maini, 2012). From the case study, Laura had recent tattoo noted to lower back. She may have contracted Hep B from the use of a dirty needle during her tattoo. Laura is Divorced for 2 years, dating for 1 year. She is sexually active with 2 partners in the last 6 months. Does not use condoms. It is unsure how she contracted HBV. It is important to note that Laura’s labs HbsAb (hepatitis B antibody) is positive, HbcAb (hepatitis B core antibody) is positive, which indicates that Laura previously had hepatitis and is now better or recovering, therefore a negative HBsAg (hepatitis B surface antigen) shows that she does not have the infection which indicates immunity to hepatitis B(Rajbhandari, & Chung, 2014).