Chamberlain College of Nursing - NR 602NR 602 Week 1, 1st TD.

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.