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Tina Jones - GI subjective data
Advanced Health Assessment (NURP 530)
Simmons University
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Tina Jones – Gastrointestinal
Subjective Data Collection: 31 of 31
(100%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
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Available:
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Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
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
Finding:
Established chief complaint
Finding:
Reports frequently occurring stomach pain
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
How are you feeling?
History of Present Illness
Finding:
Asked about onset of pain
Finding:
Reports noticing pain for "at least a month"
(Found)
Pro Tip: By establishing a timeline of Tina's abdominal pain, you're soliciting information that can help you to understand the nature and extent of her stomach pain.
Example Question:
How long have you had abdominal pain?
Finding:
Reports that pain increased gradually
(Found)
Finding:
Asked about duration of pain
Finding:
Pain begins right after finishing a meal
(Found)
Pro Tip: Soliciting information about what triggers Tina's stomach pain can allow you to understand the nature of her symptoms and most effectively treat her.
Example Question:
How long after a meal does the pain start?
Finding:
Each episode lasts "a few hours"
(Found)
Pro Tip: Soliciting information about the duration of Tina's stomach pain can allow you to understand the nature of her symptoms and most effectively treat her.
Example Question:
How many hours does the abdominal pain last?
Finding:
Asked about severity of pain on a scale
Finding:
Rates present pain as 1 or 2 out of 10
(Found)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.
Example Question:
Can you rate your current stomach pain on a scale of 0 to 10?
Finding:
Rates worst pain after eating as 5 out of 10
(Found)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 after she eats will provide a quantified and relative measurement of her condition.
Example Question:
Can you rate the stomach pain after you eat on a scale of 0 to 10?
Finding:
Rates pain when supine as a 6 or 7 out of 10
(Available)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain when she's lying down, on a scale of 1-10, will provide a quantified and relative measurement of her condition.
Example Question:
Can you rate the stomach pain when you're lying down on a scale of 0 to 10?
Finding:
Asked about character of the pain
Denies cramping pain
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does the stomach pain feel like cramps?
Finding:
Denies that abdomen is tender to the touch
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Is your stomach tender to the touch?
Finding:
Asked location of the pain
Finding:
Pain is in center of upper stomach, below breastbone
(Found)
Pro Tip: Specifying the location of pain can narrow and define where Tina's pain is occurring. Soliciting this information allows you to more accurately treat her symptoms.
Example Question:
Where is your stomach pain the worst?
Finding:
Pain does not radiate
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her pain feels like specifies the way that her symptoms and pain manifest.
Example Question:
Does the stomach pain radiate?
Finding:
Denies shoulder pain
(Found)
Pro Tip: Determining where Tina's pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has shoulder pain will help you to determine precisely where her pain is located.
Example Question:
Do you have shoulder pain?
Finding:
Denies back pain
(Found)
Pro Tip: Determining where Tina's pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has back pain will help you to determine precisely where her pain is located.
Example Question:
Do you have back pain?
Finding:
Asked about aggravating factors
Finding:
Pain occurs after eating
(Found)
Pro Tip: By determining what factors aggravate Tina's pain you can develop a treatment plan for her. Asking if her pain is worse after she eats will help you to most effectively treat Tina's symptoms.
Example Question:
Do you feel the pain after you eat?
Finding:
Pain worsens with larger meals
(Found)
Pro Tip: By determining what factors aggravate Tina's pain you can develop a treatment plan for her. Asking if her pain is worse after she eats larger meals will help you to most effectively treat Tina's symptoms.
Example Question:
Is the pain worse with larger meals?
Finding:
Reports that spicy foods increase the pain
(Found)
Pro Tip: By determining what factors aggravate Tina's pain you can develop a treatment plan for her. Asking if her pain is worse after she eats spicy food will help you to most effectively treat Tina's symptoms.
Example Question:
Does spicy food make the pain worse?
Finding:
Denies high-fat foods as an aggravating factor
(Available)
Pro Tip: By determining what factors aggravate Tina's pain you can develop a treatment plan for her. Asking if her pain is worse after she eats greasy food will help you to most effectively treat Tina's symptoms.
Example Question:
Does greasy food make the pain worse?
Finding:
Pain worsens when supine
(Available)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina if her pain is worse when she is supine will provide a relative measurement of her condition.
Example Question:
Is the pain worse when you lay down?
Finding:
Pain worsens when bending over
(Found)
Finding:
Asked about effects of pain on diet and appetite
Finding:
Reports decreased appetite
(Found)
Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina how her appetite has been will illustrate the ways in which her symptoms are manifesting.
Example Question:
How has your appetite been?
Finding:
Describes not wanting to eat out of anticipation of pain
(Found)
Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina why she has been eating less will illustrate the ways in which her symptoms are manifesting.
Example Question:
Why have you been eating less?
Finding:
Reports eating smaller meals
(Found)
Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if she has been eating smaller meals will illustrate the ways in which her symptoms are manifesting.
Example Question:
Have you been eating smaller meals?
Finding:
Reports avoiding spicy foods
(Found)
Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if she still eats spicy foods will illustrate the ways in which her symptoms are manifesting.
Example Question:
Do you still eat spicy foods?
Finding:
Asked about increased burping
Finding:
Reports burping
(Found)
Pro Tip: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina if she's been burping more would indicate that Tina has been swallowing more air recently.
Example Question:
Have you been burping?
Finding:
Burping occurs after eating
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
What medications do you take?
Finding:
Reports occasional antacid use
(Found)
Pro Tip: Tina's response to a question about pain management will reveal the severity of her pain, her health literacy, and the way she's managing her symptoms.
Example Question:
Have you been taking antacids?
Finding:
Denies frequent Advil (ibuprofen) use
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how frequently she is taking the Ibuprofen will illustrate the extent of her pain and how effectively OTC medication works for her injury.
Example Question:
How often do you take ibuprofen?
Finding:
Followed up on use of antacids and relieving factors
Finding:
Antacid brand is Tums
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what kind of antacids she takes will illustrate the extent of her pain and how effectively OTC medication works for her pain.
Example Question:
What kind of antacids do you take?
Finding:
Takes antacids every few days
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how often she takes an antacid will illustrate the extent of her pain and how effectively OTC medication works for her pain.
Example Question:
How often do you take an antacid?
Finding:
Takes between 2 and 4 antacid tablets at a time
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many antacids she takes at a time will illustrate the extent of her pain and how effectively OTC medication works for her pain.
Example Question:
How many antacids do you take at a time?
Denies past history of ulcers
(Found)
Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she ever had any ulcers will allow her to describe any historical concerns or problems she's had.
Example Question:
Have you ever had any ulcers?
Finding:
Denies gastrointestinal disease
(Found)
Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina about her gastrointestinal history will allow her to describe any historical concerns or problems she's had.
Example Question:
Do you have any gastrointestinal diseases?
Finding:
Denies past history of GERD
(Found)
Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she's ever been diagnosed with GERD will allow her to describe any historical concerns or problems she's had.
Example Question:
Have you ever been diagnosed with GERD?
Finding:
Denies past gastrointestinal surgery
(Found)
Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she's had any gastrointestinal surgeries will allow her to describe any historical concerns or problems she's had.
Example Question:
Have you had any gastrointestinal surgeries?
Finding:
Denies past history of appendicitis
(Found)
Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she's had appendicitis will allow her to describe any historical concerns or problems she's had.
Example Question:
Have you had appendicitis?
Finding:
Denies past history of cholecystitis
(Found)
Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she ever had her gallbladder removed will allow her to describe any historical concerns or problems she's had.
Example Question:
Have you ever had your gallbladder removed?
Tina Jones - GI subjective data
Course: Advanced Health Assessment (NURP 530)
University: Simmons University
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