Shadow Health - Esther Park -Cognition
Subjective:
Established chief complaint (Ans- -reports headache -reports recent memory loss -reports changes in concentration- difficulty concentrating
Established orientation (Ans- -oriented to person -oriented to place -oriented to time -somewhat oriented to situation
Asked about onset of symptoms (Ans- -reports headache began 2 days ago -reports memory loss in the last 2 days
Asked about frequency and duration of headaches (Ans- -reports headache pain has been constant -reports headache pain has gotten gradually worse since it began -reports that headaches are not episodic
Asked about location of pain (Ans- -reports headache is "up high, behind my forehead" 1 / 2
Asked about characteristics of pain (Ans- -describes headache as "pounding" or "throbbing" -reports a sensation of pressure -denies sharp or shooting pain
Asked about aggravating factors of pain (Ans- -reports not remembering if anything caused the headache -reports that lying increases headache pain
Asked about severity of pain (Ans- -reports that current pain is 4/10 -reports that pain upon arrival was 9/10
Asked about non-medication treatment and relieving factors of pain (Ans- -reports taking herbs to help headache -reports herbs were not effective -reports applying cold compress -reports cold compress provided some relief
Asked about existing health conditions (Ans- -reports hypertension
Followed up on hypertension diagnosis (Ans- -diagnosed with hypertension at age 54 -reports typical blood pressure is 120/70 -reports belief that blood pressure is well-controlled
Asked about allergies (Ans-
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