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Exam (elaborations)

NURS6512Week9Assignment:CaseStudyAssign ment:AssessingNeurologicalSymptoms

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NURS6512Week9Assignment:CaseStudyAssign ment:AssessingNeurologicalSymptoms

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2024/2025
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Sample2FORWEEK9-ASSIGNMENT


AdvancedHealthAssessment(WaldenUniversity)




Downloaded by david murimi ()

, NURS6512Week9Assignment:CaseStudyAssign
ment:AssessingNeurologicalSymptoms


Episodic/FocusedSOAPNoteTemplate




PatientInformation:

Initials:GMAge:33y.oSex:FemaleRace:AfricanAmerican

SUBJECTIVEDATA:

Chiefcomplaint:Shestates,Ihaveadroopingontherightsideofmyface

HPI:G.Misa33-year-
oldAfricanAmericanwomanwhopresentsinthecliniccomplainingofaright-
sidedfacialdrooping.Shestatesthatshenoteditafterwakingupinthemorning.Shef
urthersaysthatherrighteyehasbeenwateringcontinuously,andshecannotstopdro
olingoutofhermouthssideright.Shehasnopain.

CurrentMedications:Multivitamineveryday,Tylenol325mg-
2POevery4hoursasrequired,Ibuprofen200mg-2POasrequired,Valtrex500mg–
PO3xeveryday

Allergies:NKDA

PastMedicalHistory:Asthmawhenshewasachildandgenitalherpessomeyears
back.

PastSurgicalHistory:Cholecystectomyintheyear2000andextractionofwisdomt
eethwhileyoung
SocialHistory:Shetakesalcoholrarely;deniesmakingillicitdruguseorsmoking.
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