Gastrointestinal Shadow Health Subjective Data-Advanced Health Assessment 2021

Document Content and Description Below

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 yiel better patient dat... a. The following details are facts of t patient's case. Chief Complaint Established chief complaint Reports frequently occurring stomach pain History of Present Illness 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 This study source was downloaded by 100000827528247 from CourseHero.com on 06-08-2021 15:10:02 GMT -05:00 Support 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 Medical History 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 reliefshadow healthassesmentpracticalexamstestcasegastro [Show More]

Last updated: 1 year ago

Preview 1 out of 5 pages