SOAP note ( Nurse practitioner). Health, Medicine, Nursing Case Study

Case Study
Your Name
Subject and Section
Professor’s Name
Date of Submission
Date of visit: April 29, 2020
Biographical Data: The patient is K.W., a 48-year old, married, American woman.
Subjective Data
Chief Complaint: “I have frequent headaches, keep losing my balance, and sometime have difficulty speaking”
History of Present Illness: Patient complains of frequent headaches and episodes of dizziness for the past 2 weeks that resolve spontaneously. Her husband found her unconscious this morning and regained consciousness but she cannot recall what happened. Currently, the she has difficulty in speaking and cannot walk secondary to left-side body weakness and numbness leading to her difficulty in performing day-to-day tasks.
Allergies: Denies any known allergies
Current medication list: Non-compliant with antihypertensive medications
PMI: Patient has a hx of HTN for 10 years and hyperlipidemia. She denies hx of DM, CAD, cancer, any neurological disease, seizures, or dysphagia.
Hospitalizations/Surgeries: She denies any history of trauma but has undergone right carotid endarterectomy 2 years ago.
Family History: Father has HTN
Social History: Mrs. W. lives with her husband in a one-bedroom apartment. They do not have any children. She worked as a receptionist for the past 20 years. Patient has been smoking since she was 18 years-old (30 pack-years) and drinks wine occasionally during special dinners. The patient denies use of recreational drugs and admits that she is sedentary.
Review of Systems
GENERAL: The patient is somnolent, not in cardiorespiratory distress.
HEENT:  Eyes:  Complains of droopy eyelids on left, reports to have difficulty in seeing using her left eye. Ears: She admits to have difficulty in hearing using her left ear. Nose: Intact sense of smell, no discharges. Throat: She cannot swallow her food properly and tends to choke when drinking water. She cannot converse properly. Denies sore throat and enlargement of lymph nodes.
CADIOVASCULAR: Denies chest pain, discomfort, chest tightness, palpitation
RESPIRATION: Denies shortness of breath, dyspnea.
GASTROINTESTINAL: Denies nausea, vomiting or diarrhea. She experiences constipation from the time of her unconsciousness.
GENITOURINARY:  Denies urinary urgency, frequency, hematuria. She experiences incontinence from the time of the attack.
NEUROLOGICAL: She frequently experiences headache, dizziness, and feelings of loss of balance. Patient feels weakness on the left side of her body and she cannot speak properly.
MUSCULOSKELETAL:  Denies back pain, muscle pain, joint pain or stiffness. She cannot ambulate, raise her hand, or reach of objects. She cannot voluntarily open her left hand.
Objective Data
VITAL SIGNS
BP: 110/80 mmHg, PR: 80bpm, RR: 24 cpm, SPO2: 98%, Ht: 5’8”, Wt: 178 lbs, BMI: 27.1 (overweight)
GENERAL SURVEY: The patient is somnolent, oriented to place and person only, wheel
chair bound with posture leaning to her right, left upper limb in flexion, left lower limb in extension. She dresses appropriately to the weather and answers to question.
HEENT: She has dirty sclerae, pinkish conjunctivae, no eye discharges. (+) droopi...