SHADOW HEALTH - ESTHER PARK -
COGNITION – SUBJECTIVE EXAM 100%
SOLVED
, Established chief complaint - ANSWER-reports headache
-reports recent memory loss
-reports changes in concentration- difficulty concentrating
Established orientation - ANSWER-oriented to person
-oriented to place
-oriented to time
-somewhat oriented to situation
Asked about existing health conditions - ANSWER-reports hypertension
Followed up on hypertension diagnosis - ANSWER-diagnosed with hypertension at age
54
-reports typical blood pressure is 120/70
-reports belief that blood pressure is well-controlled
Asked about allergies - ANSWER-denies general allergies
-denies environmental allergies
-reports latex allergy
-denies food allergies
Asked about onset of symptoms - ANSWER-reports headache began 2 days ago
-reports memory loss in the last 2 days
Asked about frequency and duration of headaches - ANSWER-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 - ANSWER-reports headache is "up high, behind my
forehead"
Asked about characteristics of pain - ANSWER-describes headache as "pounding" or
"throbbing"
-reports a sensation of pressure
-denies sharp or shooting pain
Asked about aggravating factors of pain - ANSWER-reports not remembering if
anything caused the headache
-reports that lying increases headache pain
Asked about severity of pain - ANSWER-reports that current pain is 4/10
-reports that pain upon arrival was 9/10
COGNITION – SUBJECTIVE EXAM 100%
SOLVED
, Established chief complaint - ANSWER-reports headache
-reports recent memory loss
-reports changes in concentration- difficulty concentrating
Established orientation - ANSWER-oriented to person
-oriented to place
-oriented to time
-somewhat oriented to situation
Asked about existing health conditions - ANSWER-reports hypertension
Followed up on hypertension diagnosis - ANSWER-diagnosed with hypertension at age
54
-reports typical blood pressure is 120/70
-reports belief that blood pressure is well-controlled
Asked about allergies - ANSWER-denies general allergies
-denies environmental allergies
-reports latex allergy
-denies food allergies
Asked about onset of symptoms - ANSWER-reports headache began 2 days ago
-reports memory loss in the last 2 days
Asked about frequency and duration of headaches - ANSWER-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 - ANSWER-reports headache is "up high, behind my
forehead"
Asked about characteristics of pain - ANSWER-describes headache as "pounding" or
"throbbing"
-reports a sensation of pressure
-denies sharp or shooting pain
Asked about aggravating factors of pain - ANSWER-reports not remembering if
anything caused the headache
-reports that lying increases headache pain
Asked about severity of pain - ANSWER-reports that current pain is 4/10
-reports that pain upon arrival was 9/10
