Shadow Health - Esther Park - Cognition – Subjective Already Passed

Shadow Health - Esther Park - Cognition – Subjective Already Passed Established chief complaint -reports headache -reports recent memory loss -reports changes in concentration- difficulty concentrating Established orientation -oriented to person -oriented to place -oriented to time -somewhat oriented to situation Asked about onset of symptoms -reports headache began 2 days ago -reports memory loss in the last 2 days Asked about frequency and duration of headaches -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 -reports headache is "up high, behind my forehead" Asked about characteristics of pain -describes headache as "pounding" or "throbbing" -reports a sensation of pressure -denies sharp or shooting pain Asked about aggravating factors of pain -reports not remembering if anything caused the headache -reports that lying increases headache pain Asked about severity of pain -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 -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 -reports hypertension Followed up on hypertension diagnosis -diagnosed with hypertension at age 54 -reports typical blood pressure is 120/70 -reports belief that blood pressure is well-controlled Asked about allergies -denies general allergies -denies environmental allergies -reports latex allergy -denies food allergies Asked specifically about medication allergies -denies medication allergies Asked about home medications -reports medication for hypertension -denies taking vitamins -reports taking herbal remedy Asked about medication regimen adherence -reports storing medications in their containers (no pillbox) -reports that she "remembers to take most doses" -denies missing doses because of side effects -denies difficulty obtaining medications because of finances -denies difficulty obtaining medications because of transportation Followed up on last dose of home medications and compliance -does not remember when last dose of medication was -reports that she typically remembers to take her medication -reports that she may have missed doses but can't remember Followed up on medication for hypertension -reports taking quinapril (Accupril) -reports quinapril dosage: 10 mg -reports quinapril frequency: 1x daily -reports occasionally missing doses of quinapril -denies quinapril side effects Followed up on ginseng -takes ginseng because "it's good for your health" -reports taking extra ginseng to try to alleviate headache -does not know ginseng dosage -reports ginseng comes powdered in capsules Asked about family history -reports mother and father had hypertension -reports mother had DM type II -reports father had hypercholesterolemia Asked about activity level -reports high level of mobility and independence -reports moderate activity level -regularly attends fitness class -reports gardening as a hobby Asked about substance use -reports low alcohol consumption -reports no illicit drug use -reports no history of cigarette smoking Followed up about alcohol consumption -reports drinking 1 night a week -reports 1 drink per sitting -reports 4 drinks per month -reports typical drink is white wine Asked about diet -reports last meal was toast at breakfast -typically eats 3 meals -typically does not eat snacks -typical breakfast is piece of fruit or toast - typical lunch is canned soup -typical dinner is canned soup, or occasionally chicken or fish with vegetables and rice Asked 24-hour diet recall -reports she may have missed meals -unable to recall meals from yesterday -reports she doesn't think she has eaten today but isn't sure Asked about salt intake -reports being unsure of salt intake Asked about stress -reports low stress level Asked about general symptoms -denies fever -denies chills -denies night sweats Asked about review of systems for HEENT -denies impaired hearing -denies vision problems Asked about review of systems for respiratory -denies cough -denies shortness of breath -denies dyspnea on exertion -denies wheezing Asked about review of systems for cardiovascular -denies chest pain -denies palpitations -denies edema -denies claudication Asked about review of systems for gastrointestinal -reports nausea -denies vomiting -denies abdominal pain -denies difficulty swallowing -denies constipation -denies diarrhea Followed up on last bowel movement -unable to recall last bowel movement Asked about review of systems for musculoskeletal -denies recent injury -denies joint pain -denies erythema -denies edema of joints Asked about review of systems for neurological -denies weakness in extremities -reports that current headache is not typical-no frequent headaches -denies numbness or tingling Asked about review of systems for psychological -reports recent nervousness in new situations -reports recent mood changes -denies suicidal thoughts Asked about depression -denies depression Asked about living environment -reports living in a home -reports living with daughter -reports having her own room -reports appropriate amount of alone time -denies loneliness Asked about feeling safe at home -reports feeling safe at home Asked about bathing -reports being able to bathe herself -reports that her daughter reminds her to bathe -reports being able to reach every part of her body -reports being able to get in and out of shower Asked about dressing -reports being able to dress self completely -denies trouble with zippers -reports being able to tie shoes, but typically wears slip-ons Asked about toileting -reports being able to get on and off toilet -denies needing help with cleaning genitals Asked about transferring -reports being able to move in and out of bed -reports being able to move in and out of chairs -denies use of mechanical aids for transferring Asked about continence -reports full control of bowels -reports full control of bladder Asked about ability to eat independently -reports ability to get food to mouth herself -reports ability to prepare meals for herself Asked about sleeping habits -reports sleep is fair -reports sleeping less than usual -denies insomnia -reports occasional waking -denies oversleeping Asked about confusion -reports occasionally feeling confused Asked about evidence of falls -denies recent falls -denies history of falls -denies dizziness, vertigo, or syncope Asked about gait and ambulatory aids -denies gait impairment -denies bedrest -denies use of wheelchair -denies use of ambulatory aid for walking -denies balance problems Asked about skin breakdown -reports thin skin -denies open wounds -denies rashes or lesions -denies bruising -denies pruritis, itching or scratching Asked about weight changes -denies weight changes Asked about oral or dental problems -denies tooth problems and dental pain -denies issues with mouth, jaw, or gums -reports no issues with being able to chew food Asked about appetite changes -denies changes in appetite -denies feeling full quickly Asked about effects of health on social activity -reports feeling less social lately -denies that health problems are the cause of being less social -denies emotional problems are the cause of being less social Asked about patient's perception of health -reports health is good Asked about tiredness, energy levels, and fatigue -denies fatigue -reports typical energy levels are good Asked about recent ER visits or hospitalizations -denies ER visits in the last 3 months -denies hospitalizations in the last 3 months -reports previous c-section -reports cholecystectomy at 42