Established chief complaint
-reports pain
Established orientation
-oriented to person
-disoriented to place
-disoriented to time
-oriented
... [Show More] somewhat to situation
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Asked about fluid intake and hydration
-denies current thirst
-reports does not remember eating today
-reports does not remember drinking fluids today
Asked about onset, duration, and frequency of symptoms
-reports pain began last night
-reports pain has been constant
-reports that pain increased this morning
Asked about location of pain
-reports generalized abdominal pain
-reports back pain
-reports pain during urination
Asked about characteristics of pain
-reports pain during urination as "burning"
-reports back and abdominal pain as "aching"
-denies sharp or shooting pain
-denies cramping pain
Asked about aggravating factors of pain
-reports no known aggravating factors
Asked about treatment and relieving factors of pain
-denies treatment with medication at home
-denies use of heating pad
Asked about severity of pain
-patient is unable to quantify
Asked about existing health conditions
-reports history of UTIs as an adult
-reports hypercholesterolemia
Followed up on history of UTI
-reports UTIs once or twice annually
-reports typical UTI treatment is to see a doctor for antibiotics
Followed up on hypercholesterolemia
-diagnosed age 58
Asked about allergies
-denies general allergies
-denies environmental allergies
-denies latex allergy
-denies food allergies
Asked specifically about medication allergies
-denies medication allergies
Asked about home medications
-reports taking 2 medications for hypercholesterolemia
-denies taking vitamins
-denies taking herbal supplements
Asked about medication regimen adherence
-denies using a pillbox to organize medications
-reports that she occasionally misses doses "here and there" if she forgets
-denies missing doses of medication 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
-reports not being sure she took medications today- "I don't think I did"
-reports last dose of medications was yesterday
Followed up on medications for hypercholesterolemia
-reports taking Pravachol
-reports taking Lipitor
-denies knowing dosage for either
-reports taking both medications daily
-reports taking one before bed and one with breakfast, is unsure which is which
-denies side effects of either medication
Followed up on need for both statins
-reports starting Lipitor "maybe 2 months ago"
-reports continuing Pravachol
-reports not being sure if her doctor wanted her to take both
Asked about relevant family history
-reports family history of high cholesterol
-reports 2 brothers with high cholesterol and heart disease
-reports father died of heart attack
-reports mother died of stroke
Asked about sexual activity and history of STIs
-reports no recent sexual activity
-reports sexual activity with husband previously
-denies history of STIs
-reports no recent STI testing
Asked about substance use
-reports occasional alcohol use
-denies illicit drug use
-denies past tobacco use
Followed up on alcohol use
-reports occasional wine
-reports drinking "only on special occasions"
-reports drinking less than 1 drink per week [Show Less]