- Information
- AI Chat
Gastrointestinal Tina Jones Subjective Shadowhealth
Family Nurse Practitioner Ii (NUR 535)
Southern Connecticut State University
Recommended for you
Students also viewed
- Cardiovascular Shadowhealth Tina Jones Objective
- Mental Health Shadowhealth Tina Jones Documentation
- Focused Exam-Abdominal Pain Esther Parks Shadowhealth Objective
- Focused Exam-Cough Danny Rivera Shadowhealth Objective
- Focused Exam-Abdominal Pain Esther Parks Shadowhealth Subjective
- Shadow Health Gastrointestinal Tina Jones Documentation
Related documents
- Tina Jones Shadowhealth Mental Health Subjective
- Focused Exam-Cough Danny Rivera Shadowhealth Documentation
- Respiratory Shadowhealth Tina Jones Objective
- Focused Exam-Chest Pain Brian Foster Shadowhealth Documentation
- Focused Exam-Abdominal Pain Esther Parks Shadowhealth Documentation
- Focused Exam-Cough Danny Rivera Shadowhealth Subjective
Preview text
Subjective Data Collection: 31 of 31 (100%)
Chief Complaint
History of Present Illness
Your Results
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Indicates an item that you found. Indicates an item that is available to be found.
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 yie better patient data. The following details are facts o patient's case.
Established chief complaint 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 ûnishing a meal
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Medical History
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 üank 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 o 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
Conûrmed use of medications Conûrms 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
Social Determinants of Health
Review of Systems
Family History
Reports that she hasn't noticed a connection between soda intake and pain Reports drinking 6 - 8 glasses of water a day
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 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 üatus 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
Comments
Gastrointestinal Tina Jones Subjective Shadowhealth
Course: Family Nurse Practitioner Ii (NUR 535)
University: Southern Connecticut State University
Recommended for you
Students also viewed
- Cardiovascular Shadowhealth Tina Jones Objective
- Mental Health Shadowhealth Tina Jones Documentation
- Focused Exam-Abdominal Pain Esther Parks Shadowhealth Objective
- Focused Exam-Cough Danny Rivera Shadowhealth Objective
- Focused Exam-Abdominal Pain Esther Parks Shadowhealth Subjective
- Shadow Health Gastrointestinal Tina Jones Documentation
Related documents
- Tina Jones Shadowhealth Mental Health Subjective
- Focused Exam-Cough Danny Rivera Shadowhealth Documentation
- Respiratory Shadowhealth Tina Jones Objective
- Focused Exam-Chest Pain Brian Foster Shadowhealth Documentation
- Focused Exam-Abdominal Pain Esther Parks Shadowhealth Documentation
- Focused Exam-Cough Danny Rivera Shadowhealth Subjective