Week 5 SOAP note AS-Professional Nursing Skills Latest|Annual & Blood Work|

IDENTIFYING DATA Initials: A. Age: 30 Race: Caucasian Gender: Female Marital Status: Single Source: Patient – appears to be a reliable source of information, alert and orients to person, place, time, and situation; ready recall and understanding of medical HX CHIEF COMPLAINT : “I am here for my yearly physical. I also need to have blood work done because I take Topamax for vestibular migraines” HISTORY OF PRESENT ILLNESS: Onset Patient distinctly remembers her first episode. “I was a senior in college (2009). I was walking out of the library and all the sudden my ear popped and I got real dizzy. I couldn’t hear well at all. I saw the nurse n campus but she couldn’t identify anything wrong. Location Right ear Duration Symptoms come and go (episodic), Characteristics I haven’t experienced popping or dizziness since the first 5soap noteassignmentpracticalPatientnursingtestexamcase