Subjective Data Collection: 55 of 56 (98.2%)
Cate gory
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Scored
...
Subjective Data Collection: 55 of 56 (98.2%)
Cate gory
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Indicates an item that you found.
Indicates an item that is available to be found.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports headache
Reports recent memory loss
Reports changes in concentration - recent difficulty concentrating
Orientation
Oriented to time Oriented to situation
History of Present Illness
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 headache are not episodic
Asked about location of pain Reports headache is "up high, behind my forehead"
Asked about characteristics of pain Describes headache pain as "pounding"
or "throbbing"
Reports a sensation of pressure Denies sharp or shooting pain
caused the headache
Reports that lying flat increases headache pain
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
Past Medical History
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
Reports latex allergy Denies food allergy
Asked specifically about medication allergies
Denies medication allergies
Home Medications
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