NR603 week1 Soap 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 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. GASTROINTESTINAL: - nausea, - vomiting, - diarrhea, -decreased appetite. GENITOURINARY: - dysuria, - urgency, - urinary incontinence, -amenorrhea. NEUROLOGICAL: +Lethargy, + fatigue, - weakness, - difficulty with speech, - problems with gait, - burning and tingling of lower extremities. INTERGUMENTARY: -Rash MUSCULOSKELETAL: - muscle pain, HEMATOLOGIC:- rash, - bruising. LYMPHATIC: - swollen or tender nodes, - cold/heat intolerance. PSYCHIATRIC: + anxiety, +depression O: VS: T 98.9, BP 116/78, P 100, R 22 Sao2 98%. Height 5’10”, Weight 200 pounds. CAGE questionnaire results: Have you ever felt you should cut down on your drinking? No Have people annoyed you by criticizing your drinking? Yes Have you ever felt bad or guilty about your drinking? No Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? Yes PHQ-9 Score- 10 A: Assessment: Primary diagnosis Assessment: Alcohol use disorder ICD 10 F10.9: is a pattern of alcohol use that makes it difficult for one to control drinking (Heffernan, 2011). Examples include, being engrossed with alcohol, drinking, continuing to use alcohol even when it causes problems, having to drink more to get the same effect, or developing withdrawal symptoms when you rapidly decrease or stop drinking (Heffernan, 2011). Rationale: Ed drinks alcohol three to four times per week, however, we don’t know at what age he began drinking or smoking. We don’t know the quantity he drinks at a time or what he drinks.. CAGE score of>2, which shows that he has an alcohol or drinking problem. Depression ICD 10 F32.9: Depression is a mood disorder that triggers a persistent feeling of sadness and loss of interest in things that are normal occurrences (Anderson et al., 2015). Clinical depression, affects how a person feels, think and behave and can result to a variety of emotional and physical problems (Anderson et al., 2015). Symptoms: Fatigue, tiredness, lack of energy, changes in appetite (often reduced appetite and weight loss), unexplained physical problems, such as back pain or headaches, sadness, irritability, sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction (Anderson et al., 2015). Rationale: Ed has moderate depression and we don’t know a lot of information especially if there are other life- changing events in his life or in the family or a history that may predispose him to this disease. “I just feel like I don’t enjoy the activities that I used to. ” PHQ score is 10 Secondary Diagnosis Insomnia ICD 10 G47.0 is a disorder that is characterized by difficulty to falling asleep or staying asleep, or both, regardless of the opportunity for adequate sleep (Pigeon, Bishop, & Marcus, 2013). Insomnia may be primary or a secondary cause. A disease or