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”
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