Chamberlain College of NursingNR 603Week 5 case.

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Running head: WEEK 5: SUMMARY 1 Week 5: APEA Case Presentation Summary Chamberlain University NR603: Advanced Clinical Diagnosis and Practice Across Lifespan March 2018 WEEK 5: SUMMARY 2 SOAP We... ek 5 Patient Information: J.L. 30-year-old female, Asian, insurance unknown. (S) Subjective: CC: “Muscle weakness on one side of face.” HPI: 30-year-old pregnant, Asian woman, G1P0, 38 weeks, presents with complaints of unilateral pain in the left temporal and jaw area. Said this was first noticed 3 days ago. Has been feeling some nausea, swelling and just sick lately. Has noticed an elevated blood pressure, with swelling in the face. Reports that the facial swelling came on last night very quickly and when trying to drink liquids, is noticing dribbling down one side. Also is unable to close her left eye completely. Symptoms did not resolve with rest, in fact have gotten worse. Is extremely worried and anxious. Current Medications: Denies prescription medication. Takes a daily prenatal vitamin throughout pregnancy. No regular use of OTC, herbal or other supplements. Allergies: NKDA. PMHx: Denies past medical history. PSHx: Denies past surgeries. Childhood Illnesses: None reported. Immunization Hx: Up to date with all immunizations, including annual influenza. Other Screenings: Last physical/pelvic/Pap about 1 year ago. No other screening. Does monthly BSE. [Show More]

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