wk2 option 1.__ Western Michigan University__ NUR MISC__Rated A

S: waken up at night with a bitter taste in her mouth about four times per week for the past two months, interfering with her sleep. HPI Onset: 2 months Location: mouth Duration: woken up at ni ght with a bitter taste in her mouth about 4 times per week Characteristic: bitter taste Aggravating factors: taking any medications? What type of diet do you follow? Alcohol, drugs, caffeine? Relieving factors: are you doing any oral care? Does anything make it better? Treatment: currently taking any medications, even OTC? Severity: interfering with her sleep PH: ask patient for any surgical history, past medical history, family past medical history Social History: ask regarding tobacco, alcohol, drug use Allergies: ask about medication and food allergies Medications: ask about routine and OTC medications ROS: HEENT: waken up at night with a bitter taste in her mouth about four times per week for the past two months, interfering with her sleep Cardiac: ask for cardiac symptoms and or history Respiratory: ask if patient has any respiratory symptoms GI: ask for any gastrointestinal symptoms such as constipation, diarrhea, pain, n/v GU: ask for urinary symptoms, gentile abnormal symptoms O: Physical Assessment General appearance: describe current patient’s appearance and vital signs, ask for presence of fever or chills, any recent travel HEENT: waken up at night with a bitter taste in her mouth about four times per week for the past two months, interfering with her sleep. Assess oral mucosa, gingivae, lesions, bleeding, missing or damaged teeth, tongue symmetry, no tremor. Inspect for abnormal findings on the pharynx, any exudate, uvula rises midline on phonation, gag reflex, any abnormalities of the tonsils, palpate the neck, thyroid gland and lymph nodes. Evaluate for dental hygiene. When was the last dental visit? Cardiac: to be perform Respiratory: to be perform GI: evaluate for epigastric pain, acid reflux, constipation, nutrition, past medical history GU: ask and assess for urinary or gynecological symptoms Musculoskeletal: to be perform