Assignment task:
The NP further questions the patient on her symptoms. She reports that the dizziness usually lasts no more than 30 - 40 seconds. Last evening, when washing the dishes, she felt like the room was swaying. She sat down until the feeling subsided, but she states that she had some intermittent lightheadedness most of the evening. She reports that when she woke up this morning, everything seemed to be rotating, and she felt nauseated. When she sat up in bed, she initially felt worse, but after "about a minute," the movement resolved. The NP completes a thorough history-taking. Please place the following important information gathered from the patient into the correct section of the subjective data collection of the SOAP note. *Positive for nausea, no vomiting: no abdominal pain or diarrhea *Appendectomy (1958); Lens replacement surgery, left eye (2012) Past Medical History. Need Assignment Help?
* She has no allergies to medications Past Medical History *No chest pain, palpitations, or swelling
*Lives with husband, married 40 years Social History
*Current medical problems include hypertension, hyperlipidemia, generalized anxiety disorder, and osteoarthritis.
*Positive for dizziness, no numbness/tingling, no headache, no weakness -Past Medical History
*No history of tobacco use, drinks "a glass of wine" 1-2x/week with dinner, no history of illicit drug use
*Feeling of fullness to right ear, no tinnitus, no hearing loss -Social History
*Current medications include Zestril (lisinopril) 10mg daily, Lipitor (atorvastatin) 10mg daily at bedtime, Lexapro (escitalopram) 10mg daily, Xanax (alprazolam) 0.5mg TID PRN, Ambien (zolpidem) 10mg at bedtime PRN, Tylenol (acetaminophen) 650mg every 4-5 hours PRN-Past Medical History.