A 54-year old woman complain of left side drooling and facial drooping since earlier this morning.
S: Left side drooling and facial drooping since earlier this morning
HPI
Onset: when did it start? Time last known? Wh
...
A 54-year old woman complain of left side drooling and facial drooping since earlier this morning.
S: Left side drooling and facial drooping since earlier this morning
HPI
Onset: when did it start? Time last known? What were you doing when this episode occurred? Last well seen?
Location: left side of face, does it radiate anywhere else?
Duration: since earlier this morning, have you experience these symptoms before?
Characteristic: left side drooling and facial drooping. Any other symptoms?
Aggravating factors: what makes it worse? Are you
Relieving factors: what have you tried to relieve your symptoms?
Treatment: have you taken any medication? If so, what medications did you tried? How long did you take it for? did it help? How long did you take it? How frequent?
Severity: loss of sensation? Affecting any other parts of the body?
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 Immunizations: ask if current with immunizations
ROS:
HEENT: ask if patient is presenting with any URI symptoms, travel out of country, any sick contact. Are you coughing after eating or drinking? Difficulty to swallow or shocking feeling? left side drooling and facial drooping
Cardiac: ask for cardiac symptoms and or history
Respiratory: ask if patient has any respiratory symptoms or concerns
GI: ask for any gastrointestinal symptoms such as constipation, diarrhea, pain, n/v
GU: ask for urinary symptoms, any concerns with reproductive system? Musculoskeletal: experiencing any weakness on either side of the extremities? Loss of coordination or balance?
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