Identifying data: Patient C DOB: 7/28/1966 MR# 00031245
Source and reliability of history: 54-year-old female, reliable
historian. Demographics:
Gender: Female
Age: 54
Marital status: N/A
Ethnicity: N/A
Social/occupation: N/A
S: Subjective
A 54-year old woman complain of left side drooling and facial drooping since earlier this
morning.
CC: Left side drooling and facial drooling since early this morning.
HPI:
Onset: When did it start? What were you doing when this episode occurred? Last time seen
well?
Location: Left side of face, does it radiate anywhere else?
Duration: Since earlier this morning, have you experience these symptoms before?
Characteristic: Left side drooling and facial drooping. Any other symptoms?
Aggravating factors: Is there anything that makes it worse?
Relieving factors: What have you tried to relieve your symptoms?
Treatment: Have you taken any medication? If so, what medications did you tried? Have you
tried any other treatment? Did it help? How long did you take it? How frequent?
Severity: Any loss of sensation? Affecting any other parts of the body?
PMH:
Childhood Illnesses: Did you have any childhood illnesses?
Surgical History: Any surgeries?
Hospitalizations/Accidents/Injuries: Have you had any hospitalizations, accidents, or
injuries?
Transfusions: Any previous blood transfusions?
Sexual history:
Number of sexual partners- How many sex partners have you had?
Sexual orientation – What is your sexual preference?
History of sexual transmitted infections- Any history of STI’s?
Safe sex behaviors- Do you use protection during sexual contact?
, NURS 680 B WEEK 4
Psychiatric History: Any History of mental illness?
Immunizations/Health Maintenance:
Eye exam- When was your last eye exam?
Dental exam- When was your last dental exam? What were the results?
Immunizations: Are you up to date on your immunizations?
Travel History: Have you traveled recently? If so where?
Family History:
Father- Can you please tell me the age of your father, is he alive or deceased? Any
medical issues or drug allergies? Any family history of: hypertension, obesity,
diabetes, CAD, sudden death at younger age, DVT or blood disorders?
Mother- Can you please tell me the age of your mother, is she alive or deceased? Any
medical issues and drug allergies?
Sister - Can you please tell me the age of your sister, any medical issues and
drug allergies?
Brother- Can you please tell me the age of your brother, any medical issues and
drug allergies?
Psychosocial History:
Marital status/relationships- Are you married, or in a relationship?
Employment status- Are you employed? If so, what do you do for a living?
Substance abuse – Do you smoke cigarettes? Drink? Do illicit drugs?
Diet – What type of diet do you normally consume? Salt intake? What is your
usual weight? Has there been any recent change?
Sleep pattern – What is your sleep pattern like? Do you normally take naps during the
day?
Exercise- Do you exercise? If so what type? How much?
Medication History: Do you take any medications? Including over the counter and vitamins?
Allergies: Any drug allergies?
ROS:
General: Denies any fever, chills, sweats, fatigue, or weight loss? Denies tiring easily, recent
illnesses and recent travel outside of the country?
Head: Any head trauma? Denies any lumps, swelling or skin lesions. Left side drooling and
facial drooping.
Eyes: Denies having any vision problem. States that her last eye examination was in 2010.
Denies having blurry vision and photophobia.
Ears: Denies pain, discharge, tinnitus, or changes in hearing.
Nose/Sinuses: Denies epistaxis, obstruction, discharge, or olfactory changes?
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