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.
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.
