Subjective (S):

Chief Complaint (CC): Well exam, ongoing fatigue, stress, issues with falling asleep and staying asleep, and financial concerns. History of Present Illness (HPI): K.F. presents with complaints of ongoing fatigue, stress, and financial concerns. She reports difficulties with both falling asleep and staying asleep, which started when she moved in with her parents. She currently shares a room with her two younger children. K.F. recently separated from her spouse and reports an impending divorce. Additionally, she has not had a menstrual period since the birth of her last child.
  • Onset: Symptoms began after moving in with her parents.
  • Location: Generalized.
  • Duration: Every night.
  • Characteristics: Trouble falling and staying asleep.
  • Aggravating Factors: Stress, sleeping in the same room with two younger children, ongoing divorce.
  • Relieving Factors: None reported.
  • Treatment: Takes Advil PM every night and drinks a glass of wine.
Current Medications:
  • Advil PM 200 mg/38 mg, 1 cap PO nightly.
Allergies:
  • No known allergies.
Past Medical History (PMHx):
  • Reports PCOS as a teenager and has irregular menses.
  • Four pregnancies, three births, one pre-term, and one miscarriage at 10 weeks when she was 16.
  • Diagnosed with gestational diabetes during the last pregnancy and preeclampsia.
  • Two C-sections.
Social History:
  • Currently going through a divorce and recently moved in with her parents.
  • Former smoker: Smoked 1 PPD for 15 years, quit 18 months ago.
  • Drinks one glass of wine every night.
  • Does not routinely exercise.
  • Often skips breakfast and lunch; eats quick, processed dinners.
  • Not currently sexually active; has been abstinent for the last 6 months.
Family History:
  • Mother: Hypertension, hyperlipidemia, Type 2 DM, glaucoma, breast cancer (age 50, treated with lumpectomy).
  • Father: Hypertension, hyperlipidemia, MI with stenting 5 years ago.
  • Siblings: Two siblings in good health.
  • Other family members: Died of old age.

Objective (O):

Vital Signs:
  • Height: Not provided
  • Weight: Not provided
  • Blood Pressure: Not provided
  • Temperature: Not provided
  • Heart Rate: Not provided
  • Respiratory Rate: Not provided
  • SpO2: Not provided
Physical Exam:
  • Constitutional: No weight loss, fever, chills, weakness, or fatigue.
  • HEENT:
    • Eyes: No visual loss, decreased night vision, blurred vision, double vision, or yellow sclerae.
    • Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
  • Skin: No rash or itching.
  • Cardiovascular: No chest pain, pressure, discomfort, palpitations, or bilateral lower extremity edema (BLLE).
  • Respiratory: No shortness of breath, cough, or sputum production.
  • Gastrointestinal: No anorexia, nausea, vomiting, diarrhea, abdominal pain, or blood.
  • Genitourinary: No burning on urination or tenderness to palpation in the suprapubic area.
  • Neurological: No headache, dizziness, syncope, paralysis, ataxia, numbness, tingling in extremities, or changes in bowel or bladder control.
  • Musculoskeletal: No muscle, back pain, joint pain, or stiffness.
  • Hematologic: No anemia, bleeding, or bruising.
  • Lymphatics: No enlarged nodes, no history of splenectomy.
  • Psychiatric: No history of depression or anxiety.

Assessment (A):

  1. Insomnia related to stress and environmental changes: Likely related to her recent move, ongoing divorce, and sharing a room with her children.
  2. Ongoing stress and fatigue: Due to the significant life changes, including divorce and financial concerns.
  3. Amenorrhea: Possibly related to stress, hormonal imbalance (history of PCOS), or other underlying conditions.
  4. Risk of depression or anxiety: Despite the absence of a formal history, the current life stressors suggest the need for close monitoring.

Plan (P):

  1. Sleep Hygiene Counseling:
    • Educate K.F. on the importance of establishing a bedtime routine, limiting screen time before bed, and creating a restful environment.
    • Discuss the potential negative effects of using Advil PM and alcohol as sleep aids and explore alternative methods such as relaxation techniques or herbal supplements (e.g., melatonin) if appropriate.
  2. Stress Management:
    • Recommend counseling or therapy to help manage stress related to the divorce, financial concerns, and changes in her living situation.
    • Suggest mindfulness practices, such as meditation or yoga, to help reduce stress levels.
  3. Further Evaluation of Amenorrhea:
    • Order blood work to assess hormone levels, including thyroid function tests and reproductive hormones (FSH, LH, estradiol).
    • Consider a pelvic ultrasound to evaluate for any structural abnormalities given her history of PCOS and amenorrhea.
  4. Nutrition and Lifestyle:
    • Advise on the importance of regular meals and balanced nutrition to support overall health and energy levels.
    • Encourage light exercise, such as walking, to improve mood and energy levels.
  5. Follow-Up:
    • Schedule a follow-up appointment in 4-6 weeks to assess progress with sleep, stress management, and the results of any ordered tests.
    • Monitor for any signs of depression or worsening anxiety, and consider referral to a mental health specialist if needed.