Posted: December 28th, 2022
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Experts selected these topics as essential components of a strong, thorough interview with this patient.
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Established chief complaint tina jones gastrointestinal shadow health subjective data
Reports frequently occurring stomach pain
Asked about onset of pain
Reports noticing pain for “at least a month”
Reports that pain increased gradually
Asked about frequency of pain
Reports pain occurs every day
Reports 3 to 4 episodes a week that are more severe
Asked about duration of pain
Pain begins right after finishing a meal
Each episode lasts “a few hours”
Asked about severity of pain on a scale
Rates present pain as 1 or 2 out of 10
Rates worst pain after eating as 5 out of 10
Rates pain when supine as a 6 or 7 out of 10
Asked about character of the pain
Describes the pain as similar to heartburn
Denies crushing pain
Denies gnawing pain
Denies cramping pain
Denies that abdomen is tender to the touch
Asked location of the pain
Pain is in center of upper stomach, below breastbone
Pain does not radiate
Denies shoulder pain
Denies back pain
Denies arm pain
Denies flank pain
Denies pain on right side of abdomen
Asked about aggravating factors
Pain occurs after eating
Pain worsens with larger meals
Reports that spicy foods increase the pain
Denies high-fat foods as an aggravating factor
Pain worsens when supine
Pain worsens when bending over
Asked about relieving factors
Pain improves between meals
Pain improves when upright
Asked about effects of pain on diet and appetite
Reports decreased appetite
Describes not wanting to eat out of anticipation of pain
Reports eating smaller meals
Reports avoiding spicy foods
Asked about increased burping
Reports burping
Burping occurs after eating
Asked about changes in weight
Denies recent weight loss
Confirmed use of medications
Confirms medications (no new medications reported)
Reports occasional antacid use
Denies frequent Advil (ibuprofen) use
Followed up on use of antacids and relieving factors
Antacid brand is Tums
Takes antacids every few days
Takes between 2 and 4 antacid tablets at a time
Reports that antacids offer partial relief
Confirmed allergies
Confirms allergies (no new allergies reported)
Asked about past gastrointestinal history
Denies past history of ulcers
Denies gastrointestinal disease
Denies past history of GERD
Denies past gastrointestinal surgery
Denies past history of appendicitis
Denies past history of cholecystitis
Denies past history of stomach cancer
Denies past history of liver disease
Denies past history of kidney disease
Denies past history of bladder disease
Asked about typical bowel movements
Reports bowel movement every 2 days
Denies pain during bowel movements
Denies bloody or tarry stools
Denies mucus in stool
Describes consistency of bowel movements
Asked about typical urination
Reports increased urination
Reports urine is a clear or light-yellow color
Reports nocturia
Denies pain during urination
Describes urine character as normal
Denies pink or bloody urine
Denies incontinence
Asked about menstruation and sexual activity
LMP was 3 weeks ago
Denies sexual activity
Asked about most recent meal
Most recent meal was breakfast this morning
Most recent meal was toast with butter and honey and orange juice
Asked 24-hour diet recall
Yesterday’s breakfast was cereal
Yesterday’s lunch was pizza
Yesterday’s dinner was a baked potato
Asked about typical diet
Reports typical intake is 3 meals a day plus snacks
Typical breakfast is cereal, bread, or a muffin
Typical lunch is a sandwich and chips
Typical dinner is chicken, a vegetable or potatoes, and bread
Reports fast food intake 3 times a week
Typical snack is pretzels, French fries, crackers or chips
Asked about typical beverages
Last alcoholic drink was 2 weeks ago
Typical alcohol frequency is 2 – 3 times a month tina jones gastrointestinal shadow health subjective data
Typical alcohol intake is 2 – 3 drinks at a time
Reports that alcohol intake bothered her stomach
Reports drinking soda
Reports drinking 3 – 4 diet cokes a day
Reports that she hasn’t noticed a connection between soda intake and pain
Reports drinking 6 – 8 glasses of water a day tina jones gastrointestinal shadow health subjective data.
Asked about recent dietary and life experiences
Denies recent travel
Denies food poisoning
Asked about substance use
Denies illicit drug use
Denies cigarette smoking
Asked about food access tina jones gastrointestinal shadow health subjective data.
Reports living near grocery store
Reports access to fresh foods
Asked about general symptoms
Denies fever
Denies chills
Denies fatigue
Denies night sweats
Asked about review of systems for mental health
Reports occasional feelings of anxiety
Reports feelings of stress
Asked about review of systems for gastrointestinal
Denies nausea
Denies vomiting
Denies diarrhea
Denies constipation
Denies flatus
Denies bloating
Asked about review of systems for respiratory
Denies sore throat
Denies coughing
Denies dysphagia
Denies difficulty breathing
Denies chest pain
Denies palpitations
Denies change in sense of taste
Asked about relevant family history
Reports family history of colon cancer
Denies family history of GERD
Denies family history of IBS
Denies family history of cholecystitis
Denies family history of liver disease
Denies family history of kidney disease
Denies family history of bladder disease tina jones gastrointestinal shadow health subjective data
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