LAB Sheet of Nursing Clinical Assessment of Adult Health Head, Neck and Lymph Nodes-File Update

Allergies: Client states that she has no allergies to foods, medications or environment. Current Medication: Client states that she is taking Rizatriptan 10mg P.O PRN for migraine headaches and Ibuprofen 200-400mg P.O. PRN for migraine headaches. Client denies using in supplements, herbal medications or homeopathic remedies. FH: Family History Client states that Father has migraine headaches and maternal grandmother has a history of hypothyroidism. PMH: Past Medical History: Client has a history of migraine headaches and is taking prescription medication. Client states that she had chicken pox when she was 5 years old. Client says that she has no history of sexually transmitted diseases, no history of mumps, cold sores or shingles. SH: Surgical History Client states that she has never had any head, neck or lymph node surgery SH: Social History: Client states that she does not drink alcohol in any form, on illicit or street drugs and no smoking of tobacco or tobacco products such as vaping. COLDERRAA C Client states that she woke up this morning and “I can’t close my right eye or control one side of my faced” O Client states that she woke up this morning like this. Problem started today. L Client states, and nurse observes client’s face is right side affected. D Client states “I’ve never experienced anything like this ever” “It started this morning” E Client states that there was “no warning”, she states that she felt fine before bed last night and woke up like this”. Client states last migraine was over 2 mos ago. R No other areas of the body appear affected. Negative for stroke signs and symptoms. R Client states that the symptoms have remained constant since she woke up this morning. A Client states that she woke up with the subjective and objective symptoms. A Client states that there was “no warning” before this morning.