Walden University - NURSING: NURS6512 Health Assessment Week 9 discussion: SOAP NOTE Case Study #3. Graded A. SOAP NOTE

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SOAP NOTE Case Study #3 Patient Initials: __MH___ Age: _33____ Gender: __F____ SUBJECTIVE DATA: Chief Complaint (CC): Drooping on the right side of face History of Present Illness (H... PI): MH is a 33-year-old Caucasian female who presents today with right side facial drooping. She says that she noticed it when she woke up this morning. She says that her right eye has been watering constantly, and that she can’t stop drooling out of the right side of her mouth. She has no pain. Medications: 1.) Multivitamin daily 2.) Ibuprofen 200mg-2 PO as needed 3.) Tylenol 325mg-2 PO every 4 hours as needed 4.) Valtrex 500mg – PO 3 x daily (for genital herpes outbreak) Allergies: NKA Past Medical History (PMH): 1.) Asthma – when she was a child 2.) Genital herpes- 2010 Past Surgical History (PSH): 1.) Cholecystectomy 2000 2.) Wisdom teeth extraction 1990 Sexual/Reproductive History: Heterosexual G1P1A0 Menarche age 13, cycles q 28-30, flow: 5-6 days. Mild dysmenorrhea; responds to ibuprofen. Last PAP 2 years ago and normal. Personal/Social History: She drinks occasionally; denied denies smoking or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last October, and had a tetanus shot two years ago when she cut her arm on a piece of metal. Significant Family History: One brothers with hypertension, dx at age 50. She has one son in her 20s, healthy, living at home. Lifestyle: She is divorced and lives alone with her daughter in a nice neighborhood with a low crime rate. She does not exercise daily but says she takes her dog for a short walk daily. She has a primary care nurse practitioner provider and goes for her yearly checkups and when she is sick. She had a PAP smear done two years ago. She has not had a mammogram, but says she does monthly self-exams. She has a healthy diet and eating pattern. She has a good support system composed of family and friends. Review of Systems: [Show More]

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