NURS 6512: Advanced Health Assessment and Diagnostic ReasoningINITIAL POST Episodic/Focused SOAP Note Patient Information:Initials: L. K.Age: 33Sex: FemaleRace: CaucasianSUBJECTIVE:CC (chief complaint): “Drooping of the right side of face.” Excessive tearing and drooling. HPI: Laura King is a 33-year-old Caucasian female who presents to the clinic today with complaints of drooping of the right side of her face, excessive tearing and drooling also on the affected side. She is very alarmed, reports no pain with this condition. Just the appearance is frightening and the fact that she can’t control her secretions. Location: Right side of face/ mouth/ right eyeOnset: This morningCharacter: “Drooping of the face”; excessive tearing from right eye; drooling from right side of mouth. Timing: This morningExacerbating/relieving factors: None reported. Patient states no pain just feels “numb”Severity: 0/10. Patient states no pain. Current Medications: 1.Metformin (Glucophage): 500mg PO daily.Allergies: No known allergiesPast Medical History: Patient has Type 2 Diabetes Mellitus.Immunizations are up to date. Last influenza vaccine: 2018. Last pneumococcal vaccine: Unknown. Last Tetanus shot: Unknown. No other hospitalizations or surgeries per patient.Social History: Laura has been married for 8 years to her husband, they have 2 children. Laura works as a nurse at a local hospital, where she stands for 12 hours. Her floor is in mandatory overtime which means more time up on her feet and more stress to get other responsibilities accomplished outside of work. She is exhausted both mentally and physically from work and
feels extremely tired the majority of the time. Patient denies tobacco use, is a social drinker at family/friends gathering, but not a daily drinker. No illicit drug use reported.
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- Summer '15
- pulse, Facial nerve, Paralysis