Case Study: Patient Experiencing Tiredness and Difficulty Sleeping

Case Study: Patient Experiencing Tiredness and Difficulty Sleeping

Case Study: Patient Experiencing Tiredness and Difficulty Sleeping

NR 603 Week 5 APEA Predictor Results Paper

Patient Information:  A.C., 26 y/o Hispanic female. Preferred IPA (EHP)

(S) Subjective:

CC: “Feeling tired and difficulty sleeping.”

HPI: A.C.is a 26 y/o G1T1P0A0L1 who presents for a postpartum visit and also reports feeling very tire and having difficulty falling asleep and staying asleep. She is 6 weeks postpartum following a spontaneous vaginal delivery. The delivery was full term. Patients reports that her labor lasted about 14 hours and she had epidural injection.  Baby’s course has been uneventful with the exception that sometimes cries for no apparent reason and does not want to latch onto the breast. Patient reports that she became worry and took the baby to the Pediatrician 2 weeks prior and the doctor re-assured her that the baby was healthy. Patient reports no problems voiding, no vaginal  bleeding and no abnormal discharge; but, does report intermittent pelvic pain and cramps. She also reports that no sexual activity has been resumed and she states not having any desire to do so.  In addition, she reports feeling sad and has cried a few times for no apparent reason. She also does not feel like going out even though her friends have invited her to go out. She states that she does not have anyone to leave the baby with and she does not want to go out with friends and bring the baby with her.

Current Medications:

Ibuprofen 500mg every 4-6hrs  as needed for back pain and cramps.

Women’s multivitamins.

Allergies: No known allergies.

PMHx:

Iron Deficiency Anemia

Seasonal Allergies

Vaginitis

GERD

 PSHx: Pt status is single but has a boyfriend (baby’s father). She initiated sexual activity at the age of 16 and has had multiple partners. Patient has been using birth control pills until she became pregnant; the pregnancy was not planned.  Denies smoking, drug use, and only drinks when going out with friends. Currently living with mom, siblings, and her boyfriend. She used to work as a receptionist but is currently unemployed, and her boyfriend is paying for all their living expenses ……… document continue