Patient Intake Record
Case Report
Patient's Name: Perez, B
Gender: Female
Date of Birth: 06/XX/1985
Occupation: Registered Nurse
Marital Status: Single
Private
Phone [HIDDEN] Private
Chief Complaint: Bell's palsy
History of Present Illness:
The patient states she first felt numbness on her tongue 10 days ago. When she woke up in the morning and was cleaning her teeth, the water was dripping from her mouth. Her right eye was not able to close completely, and she felt numbness on the right side of her face.
Medical History:
The patient consulted with her doctor who confirmed the diagnosis as Bell's palsy; her doctor prescribed prednisone for 14 days. The patient came to see me on 8/29/2013. The patient states she has pain and numbness on the right side of her face, drooling, loss of the ability to taste, and her right eye cannot fully open or close and has excessive tearing.
Personal History:
Menstrual History: She is taking birth control pills.
LMP: N/A
Obstetrical History: None
Smoking/Addiction/Alcohol History: None
Family History: Her mother had Bell's palsy.
Current Medications and Herbs: She is taking Prednisone (Corticosteroids, Anti-inflammatory).
Review of Systems:
Energy: Tired
Sleep: Ok
Mood: Since she is a nurse and continues to work with this condition, it causes her emotional distress because of its characteristic drooping appearance around the eye and mouth, thus adversely effecting self-esteem and work experience.
Appetite/Thirst: Normal appetite. No thirst.
Digestion: Good
Bowels: 1/day, little loose.
Urine: o.k.
(O) Examination
HEENT: Pain and paralysis on right side of face.
Drooling mouth and loss of ability to taste.
Eye cannot fully close on the right...
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