S: waken up at night with a bitter taste in her mouth about four times per week for the past
two months, interfering with her sleep.
HPI
Onset: 2
... [Show More] months
Location: mouth
Duration: woken up at night with a bitter taste in her mouth about 4 times per week
Characteristic: bitter taste
Aggravating factors: taking any medications? What type of diet do you follow? Alcohol, drugs, caffeine?
Relieving factors: are you doing any oral care? Does anything make it better?
Treatment: currently taking any medications, even OTC?
Severity: interfering with her sleep
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
ROS:
HEENT: waken up at night with a bitter taste in her mouth about four times per week for the past two months, interfering with her sleep
Cardiac: ask for cardiac symptoms and or history
Respiratory: ask if patient has any respiratory symptoms
GI: ask for any gastrointestinal symptoms such as constipation, diarrhea, pain, n/v
GU: ask for urinary symptoms, gentile abnormal symptoms
O:
Physical Assessment
General appearance: describe current patient’s appearance and vital signs, ask for presence of fever or chills, any recent travel
HEENT: waken up at night with a bitter taste in her mouth about four times per week for the past two months, interfering with her sleep. Assess oral mucosa, gingivae, lesions, bleeding, missing or damaged teeth, tongue symmetry, no tremor. Inspect for abnormal findings on the pharynx, any exudate, uvula rises midline on phonation, gag reflex, any abnormalities of the tonsils, palpate the neck, thyroid gland and lymph nodes. Evaluate for dental hygiene. When was the last dental visit?
Cardiac: to be perform
Respiratory: to be perform
GI: evaluate for epigastric pain, acid reflux, constipation, nutrition, past medical history
GU: ask and assess for urinary or gynecological symptoms
Musculoskeletal: to be perform [Show Less]