NR 602 Week 1, 1st TD: Well-Woman Exam for Kayla

Well-Woman Exam for Kayla Patient Information: KF, 37, F, Latin American S. CC (chief complaint): “I am here for a physical exam.” Reports fatigue and trouble falling and staying asleep at night. HPI: Onset: About 8 weeks ago Location: n/a Duration: daily at night for sleep problems, constant for fatigue Characteristics: Hard time falling asleep and staying asleep. Feeling tired all the time. Aggravating Factors: Stress, financial worries, and sleeping in the same room as children. Relieving Factors: No information given. Treatment: Taking Advil PM and drinking a glass of wine every night to help with sleep. Current Meds: No current medications. Takes Advil PM at night or sleep prn. Allergies: NKDA. PMHx: In general good health. No surgeries or hospitalizations other than childbirths. Four Pregnancies: 3 births (1 pre-term, 2 C-sections). One miscarriage at 10 wks at the age of 16. PCOS diagnosed as teenager with irregular menses. Gestational diabetes with last pregnancy. No information given for immunization status. Doesn’t know date of last tetanus. Social History: Recently separated from husband. Moved to the area with her children to live with parents. Three children, ages 13 months, 5 yrs, and 15 yrs. Trying to resolve marital issues, in marital counseling. Reports financial worries, stress and ongoing fatigue. Former smoker, smoked 1 PPD x 15 yrs, quit smoking 18 months ago when pregnant. Drinks a glass of wine every night to sleep. Does not exercise routinely. Often skips breakfast and lunch. Family diet consists largely of processed, quick food. Family History: Mother with hyperlipidemia, Type 2 DM, and HTN. Father with HTN, hyperlipidemia, and an MI with stenting 2 yrs ago. Children all healthy. ROS: CONSTITUTIONAL: (+) fatigue, (+) stress, (+) unable to fall asleep and stay asleep CARDIOVASCULAR: no information given RESPIRATORY: no information given GASTROINTESTINAL: (+) skips breakfast and lunch, (+) consume quick, processed food daily. REPRODUCTIVE: (+) No menses since birth of last child NEUROLOGICAL: no information given MUSCULOSKELETAL: no information given HEMATOLOGIC: no information given PSYCHIATRIC: (+) stress ENDOCRINOLOGIC: no information given O. Vital signs: height: 155 centimeters, weight: 65.5 kilograms. B/P: 130/76, HR: 82, T: 98.7, Resp: 16, SpO2: 97%. BMI 27.3 (Overweight)