Initials: GM Age: 33 y.o Sex: Female Race: African American
SUBJECTIVE DATA:
Chief complaint: She states, I have a drooping on the right side of my face
HPI: G.M is a 33-year-old African American woman who presents in the clinic complaining of a right-sided facial drooping. She states that she noted it after waking up in the morning. She further says that her right eye has been watering continuously, and she cannot stop drooling out of her mouths side right. She has no pain.
Current Medications: Multivitamin every day, Tylenol 325mg-2 PO every 4 hours as required, Ibuprofen 200mg-2 PO as required, Valtrex 500mg – PO 3 x every day
Allergies: NKDA
Past Medical History: Asthma when she was a child and genital herpes some years back.
Past Surgical History: Cholecystectomy in the year 2000 and extraction of wisdom teeth while young
Social History: She takes alcohol rarely; denies making illicit drug use or smoking.
Family History: She has one brother with hypertension and a daughter who is 13years old healthy and living at home
Immunizations History: Her vaccinations are up to date. She had a flu vaccine lastly on February and had tetanus shot the previous two years when she had injured her arm on a metal piece.
REVIEW OF SYSTEMS
General: Pleasant 33-year-old woman posing in a chair talking reasonably fast. She appears very worried and is anxious; she has had a stroke. She is a good historian.
HEENT: No variations in hearing or vision; she had an eye test previous two years. GL stated no glaucoma, floaters, diplopia, photophobia, or extreme tearing history. She never before had any current infections of the ear, release, or tinnitus from her ears. Intact smell sense. GL has had no epistaxis episodes. She has no nasal polyp’s history or current sinus infection. Her previous dental examination was three years. She denied lesions, ulceration, bleeding gums, gingivitis, and she has no dental applications. No trouble swallowing or eating.
Throat: No sneezing, loss of hearing, congestion, sore throat, or runny nose.
Skin: No itching or rash.
Cardiovascular: No chest distress, palpitations murmurs, no history of arrhythmias, paroxysmal nocturnal dyspnea, orthopnea, claudication, or edema history.
Respiratory: Denied hemoptysis and has no trouble breathing at rest.
Gastrointestinal: No nausea. No abdomen ache, no variations in the bowel pattern.
Genitourinary: No variation in her urinary form, incontinence, or dysuria. GL is heterosexual. She has consistent menses. Human Papilloma Virus is positive and is not sexually active presently.
Neurological: No episodes of syncopal or dizziness, headaches, and paresthesia. No variation in the original patterns; no abnormal movements or twitches; no gait disorder history or difficulties with coordination. No seizure or falls history.
Musculoskeletal: No myalgia or arthralgia, gout or restraint in her motion range by the report, no arthritis. No history of fractures or trauma.
Hematologic: No anemia, bleeding, or bruising.
Lymphatic: No itching or staining, rashes. G.I use lotion to avert dry skin. No skin cancer history or removal of the lesion. She has no blood loss conditions, clotting problems, or transfusions history.
Psychiatric: No depression or anxiety history. No delusions sleep disruption or a history of mental condition. Denied homicidal or suicidal history
Endocrine: No signs of endocrine or hormone therapies
Allergies: She has no recognized immune shortages. Had an HIV test lastly the previous two years
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P: 120/80, RR 18, T 98.8 orally; Wt. 115, Ht: 5’2 and BMI 21
General: Nothing Abnormal Detected, appears to be contented
HEENT: EOMI, PERRLA, clear oronasopharynx; extreme tearing right eye; faces right side drooping as well as mild nasolabial fold destruction
Neck: No JVD or legally and bruit
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