Gastrointestinal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509
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Lab Pass
Subjective Data Collection: 30 of 30 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Patient Data
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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 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
https://www.coursehero.com/file/36352185/NR-509-Gastrointestinal-Subjective-Shadowpdf/ 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 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 Denies past history of ulcers
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
Social History
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
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
Asked about recent dietary and life experiences
Denies recent travel Denies food poisoning
Asked about substance use Denies illicit drug use Denies cigarette smoking
Review of Systems
Asked about general symptoms Denies fever Denies chills Denies fatigue Denies night sweats
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