Established chief complaint
-reports headache
-reports recent memory loss
-reports changes in concentration- difficulty
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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 [Show Less]