*NURSING > SHADOW HEALTH > Subjective Data Collection: 55 of 56 (98.2%) (All)
Subjective Data Collection: 55 of 56 (98.2%)
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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 Que... stions. 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 .......................................................................continued................................................................................... [Show More]
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