Tina Jones Shadow Health Gastrointestinal Results
Tina Jones Shadow Health Gastrointestinal Results
Experience Overview
Patient: Tina Jones
Digital Clinical Experience Score
98.1%
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 84.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Student Performance Index
| 52
out of 53 |
Proficiency Level:
Proficient
Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.
Subjective Data Collection
31
out of
31
Objective Data Collection
18
out of
18
Education and Empathy
3
out of
4
Time
| 70 minutes total spent in assignment |
Interaction with patient
70 minutes
Transcript
Started: Apr 15, 2025 | Total Time: 70 min
All Lines (113)Interview Questions (46)Statements (3)Exam Actions (64)
| Hi, my name is Mileidy. I will be your nurse today | Greet 04/15/25 4:59 AM EDT |
|
| Hey. | ||
| What brings you here today? | Question 04/15/25 5:00 AM EDT |
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| I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me. | ||
| I am sorry for that | Empathize 04/15/25 5:00 AM EDT |
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| I appreciate you telling me that. | ||
| How often do you have bowel movements? | Question 04/15/25 5:03 AM EDT |
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| Usually every other day. | ||
| When did the stomach ache start? (Clarified to When did the abdominal discomfort begin?.) | Question 04/15/25 5:03 AM EDT |
|
| Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad. (Clarified to when the abdominal discomfort began.) | ||
| Do you experience constipation? | Question 04/15/25 5:04 AM EDT |
|
| No. | ||
| Have you had diarrhea recently? | Question 04/15/25 5:04 AM EDT |
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| No. | ||
| What color is your stool? | Question 04/15/25 5:05 AM EDT |
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| Uh… usually light or dark brown, I guess? | ||
| How frequent is the pain? | Question 04/15/25 5:07 AM EDT |
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| It started really gradually, so I didn’t notice for awhile that it was happening more and more often. Now it’s like, every day. | ||
| WHat is the duration of the pain? | Question 04/15/25 5:08 AM EDT |
|
| For a few hours after I eat. | ||
| How severe is the pain on a scale of 0-10? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.) | Question 04/15/25 5:08 AM EDT |
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| Right now, it’s like a 1 or 2. But after I eat, it’s like a. . . 5? (Clarified to how I would rate my pain on a scale.) | ||
| How can you describe the pain? | Question 04/15/25 5:08 AM EDT |
|
| Um, it feels like heartburn. But sometimes, if it’s bad, it’s sharper than that. | ||
| Where is the location of the pain? | Question 04/15/25 5:09 AM EDT |
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| It’s like… my upper stomach. Like right below my breastbone, in the middle. | ||
| What relieves the pain? | Question 04/15/25 5:09 AM EDT |
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| I feel the best in-between meals. And sitting up on the couch seems to help. And sometimes I take an antacid. | ||
| How is your appetite? | Question 04/15/25 5:10 AM EDT |
|
| I haven’t been wanting to eat lately. | ||
| Do you have burping? | Question 04/15/25 5:10 AM EDT |
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| Yeah, that’s been happening after I eat. | ||
| Have you noticed changes in weight? | Question 04/15/25 5:11 AM EDT |
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| No, I don’t think so. | ||
| Do you use any medication? | Question 04/15/25 5:11 AM EDT |
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| I have a daily inhaler. And I’ve been taking antacid chews sometimes for my stomach, too. | ||
| How often do you take antacids? | Question 04/15/25 5:11 AM EDT |
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| I take them every few days. Just if the heartburn gets bad. | ||
| Antacids actually works best when you take them before a meal | Educate 04/15/25 5:14 AM EDT |
|
| That makes sense. | ||
| What are the common foods that you take? (No matching questions found.) | Question 04/15/25 5:15 AM EDT |
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| Which foods do you take? | Question 04/15/25 5:15 AM EDT |
|
| Oh, I know vegetables are healthy. Anything with vegetables is going to be healthier. I mean, an extra-healthy meal at our house would be baked chicken and some green beans. I make that like once a week. | ||
| What is you typical diet? (Clarified to What do you eat in an average day?.) | Question 04/15/25 5:15 AM EDT |
|
| Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to what I typically eat in a day.) | ||
| Your meal has a high level of carbohydrate which is not recommended for diabetes patients. | Educate 04/15/25 5:16 AM EDT |
|
| Sure, I think I understand what you mean. | ||
| Do you have any allergy? | Question 04/15/25 5:18 AM EDT |
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| Yeah, I’m allergic to cats. | ||
| Do you have a history of GERD? | Question 04/15/25 5:19 AM EDT |
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| I’m not really sure what GERD is. I’ve never been diagnosed with it, or anything. [AUDIO COMING SOON] | ||
| Does the stomach pain radiate? | Question 04/15/25 5:22 AM EDT |
|
| No, it’s right in the center of my stomach, like between my belly button and my ribs. | ||
| Does it hurt after you eat? | Question 04/15/25 5:22 AM EDT |
|
| Yes. Every time I eat it hurts. I’ve been eating less because I don’t like being in pain. | ||
| Have you ever been hospitalized? | Question 04/15/25 5:25 AM EDT |
|
| I went a bunch of times when I was little, for asthma attacks, then a few months ago–I guess it’s been about six months, now–I went in for my foot. | ||
| Have you had any surgery? | Question 04/15/25 5:26 AM EDT |
|
| Nope. No surgeries. . . I’ve been lucky. | ||
| Do you drink alcohol? | Question 04/15/25 5:28 AM EDT |
|
| Not lately, but I do every so often. | ||
| How many times a week do you drink alcohol? | Question 04/15/25 5:28 AM EDT |
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| I don’t drink every week — I only drink a few times a month. | ||
| How many drinks do you have at a time? | Question 04/15/25 5:29 AM EDT |
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| Never any more than 2 or 3. | ||
| Have you traveled recently? | Question 04/15/25 5:29 AM EDT |
|
| No. I’ve been here in Shadowville working my butt off! | ||
| Do you smoke cigarettes? | Question 04/15/25 5:30 AM EDT |
|
| No, I’ve never smoked a cigarette in my life. | ||
| Does your family have a history of bowel movements? (No matching questions found.) | Question 04/15/25 5:32 AM EDT |
|
| Does your family have a history of bowel disease? (Clarified to Do you have a family history of irritable bowel syndrome?.) | Question 04/15/25 5:32 AM EDT |
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| No, I haven’t heard anything about that. (Clarified to if I have a family history of irritable bowel syndrome.) | ||
| Do you have liver problem? (Clarified to Have you ever had problems with your liver?.) | Question 04/15/25 5:33 AM EDT |
|
| No, I’ve never had any problems with my liver. (Clarified to if I have had liver problems.) | ||
| Do you have kidney problem? | Question 04/15/25 5:34 AM EDT |
|
| No. As far as I know, I’ve never had anything wrong with my kidneys. | ||
| Do you have a sore throat? | Question 04/15/25 5:35 AM EDT |
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| No, my throat doesn’t hurt. | ||
| Do you have any mental issue? | Question 04/15/25 5:36 AM EDT |
|
| No, definitely not. | ||
| Do you have fever or fatigue? | Question 04/15/25 5:36 AM EDT |
|
| No. No fever. | ||
| Do you have access to fresh foods? | Question 04/15/25 5:37 AM EDT |
|
| There’s a grocery store pretty near Mom’s house so that’s where I usually go. It has pretty good produce. [AUDIO COMING SOON] | ||
| Tested skin turgor on forearm | Exam Action 04/15/25 6:40 AM EDT |
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| Inspected right side of abdomen | Exam Action 04/15/25 6:40 AM EDT |
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| Inspected front of abdomen | Exam Action 04/15/25 6:41 AM EDT |
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| Inspected left side of abdomen | Exam Action 04/15/25 6:41 AM EDT |
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| Inspected front of abdomen | Exam Action 04/15/25 6:41 AM EDT |
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| Inspected right side of abdomen | Exam Action 04/15/25 6:41 AM EDT |
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| Inspected front of abdomen | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in anterior right upper lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in anterior left upper lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in anterior right middle lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in anterior right lower lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in anterior left lower lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior left upper lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior right upper lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior left lower lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior right lower lobe | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 04/15/25 6:41 AM EDT |
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| Auscultated aortic area with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated pulmonic area with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated pulmonic area with the diaphragm | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated pulmonic area with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated Erb’s point with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated Erb’s point with the diaphragm | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated Erb’s point with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated tricuspid area with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated mitral area with the bell | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated right upper quadrant | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated left upper quadrant | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated right lower quadrant | Exam Action 04/15/25 6:42 AM EDT |
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| Auscultated left lower quadrant | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated aorta in abdomen | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated right renal artery | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated left renal artery | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated right iliac artery | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated left iliac artery | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated right femoral artery | Exam Action 04/15/25 6:43 AM EDT |
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| Auscultated left femoral artery | Exam Action 04/15/25 6:43 AM EDT |
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| Percussed left upper quadrant | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed left lower quadrant | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed right upper quadrant | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed right lower quadrant | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed left flank for CVA tenderness | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed right flank for CVA tenderness | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed spleen | Exam Action 04/15/25 6:44 AM EDT |
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| Percussed for liver span: 7 cm in the mid-clavicular line | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated right upper quadrant with deep pressure: No masses | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated left upper quadrant with deep pressure: No masses | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated right lower quadrant: with deep pressure: No masses | Exam Action 04/15/25 6:45 AM EDT |
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| Palpated left lower quadrant with deep pressure: No masses | Exam Action 04/15/25 6:46 AM EDT |
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| Palpated liver: Palpable 1 cm below right costal margin | Exam Action 04/15/25 6:46 AM EDT |
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| Palpated for spleen: Not palpable | Exam Action 04/15/25 6:46 AM EDT |
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| Palpated for right kidney: Not palpable | Exam Action 04/15/25 6:46 AM EDT |
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| Palpated for left kidney: Not palpable | Exam Action 04/15/25 6:46 AM EDT |
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| Do you have normal bowel movements? | Question 04/15/25 6:54 AM EDT |
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| Um, I don’t go every day… I probably go every two days. That’s normal for me. | ||
| How is your urination? | Question 04/15/25 6:56 AM EDT |
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| I just have to pee a lot, but it’s not really a problem. | ||
| How is your sexual activity? | Question 04/15/25 7:00 AM EDT |
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| Uh, I wouldn’t say I have a “sex life” right now. | ||
| How is your menstruation? | Question 04/15/25 7:02 AM EDT |
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| My periods are always the same–They’re bad. Cramps. Lots of bleeding for more than week. | ||
| Do you have normal sexual activity? (Clarified to Are you sexually active?.) | Question 04/15/25 7:02 AM EDT |
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| Um, not right now. (Clarified to if I am sexually active.) | ||
| What was your most recent meal? | Question 04/15/25 7:03 AM EDT |
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| This morning, I had toast with butter and honey, and some orange juice. | ||
| Do you recall what you have eaten for the last 24 hours? (Clarified to Can you tell me what you ate in the last day?.) | Question 04/15/25 7:04 AM EDT |
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| Um …Yesterday, I had … Let me start at breakfast. I had a bowl of cereal. For lunch … I had a piece of pizza. For dinner, I made baked potatoes with broccoli and cheese soup. This morning I had toast with butter and honey, and some orange juice, and that’s the last thing I’ve had. (Clarified to what I have eaten in the past twenty four hours.) |
Subjective Data Collection: 31 of 31 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
- Found:
Indicates an item that you found.
- Available:
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 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)
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:
Did the abdominal pain start suddenly?
Finding:
Asked about frequency of pain
Finding:
Reports pain occurs every day
(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:
Do you have abdominal pain every day?
Finding:
Reports 3 to 4 episodes a week that are more severe
(Available)
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 many times a week do you have abdominal pain?
Finding:
Asked about duration of pain
Finding:
Pain begins right after finishing a meal
(Available)
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
Finding:
Describes the pain as similar to heartburn
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does the pain feel like heartburn?
Finding:
Denies crushing pain
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Is the pain crushing?
Finding:
Denies gnawing pain
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Is the pain gnawing?
Finding:
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
(Available)
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
(Available)
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
(Available)
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:
Denies arm pain
(Found)
Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if either arm hurts will help you to determine precisely where her pain is located.
Example Question:
Does either arm hurt?
Finding:
Denies flank pain
(Available)
Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has flank pain will help you to determine precisely where her pain is located.
Example Question:
Do you have flank pain?
Finding:
Denies pain on right side of abdomen
(Available)
Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has pain on the right side of her stomach will help you to determine precisely where her pain is located.
Example Question:
Do you have pain on the right side of your stomach?
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
(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 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
(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 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
(Available)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina if her pain is worse when she bends over will provide a relative measurement of her condition.
Example Question:
Is the pain worse when you bend over?
Finding:
Asked about relieving factors
Finding:
Pain improves between meals
(Found)
Pro Tip: Pain might change over time for a variety of reasons. Asking Tina if her pain improves between meals establishes a timeline of when her symptoms are most aggravated.
Example Question:
Does your pain improve between meals?
Finding:
Pain improves when upright
(Found)
Pro Tip: Pain might change for a variety of reasons. Asking Tina if her pain improves when she is standing will solicit information about which positions are least uncomfortable for Tina.
Example Question:
Does your pain improve when you sit up?
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
(Available)
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
(Available)
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: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina when she burps the most would indicate that Tina has been swallowing more air recently.
Example Question:
When do you burp the most?
Finding:
Asked about changes in weight
Finding:
Denies recent weight loss
(Found)
Pro Tip: Foundational questions about general health and wellbeing can help you to determine how your patient perceives her health. Asking Tina if her weight changed recently can indicate whether Tina has concerns about recent weight loss.
Example Question:
Have you lost weight recently?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirms medications (no new medications reported)
(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
(Available)
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
(Available)
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
(Available)
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?
Finding:
Reports that antacids offer partial relief
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if the antacids have been helping will illustrate the extent of her pain and how effectively OTC medication works for her injury.
Example Question:
Do the antacids help?
Finding:
Confirmed allergies
Finding:
Confirms allergies (no new allergies reported)
(Found)
Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.
Example Question:
Have you had any new allergies?
Finding:
Asked about past gastrointestinal history
Finding:
Denies past history of ulcers
(Available)
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
(Available)
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
(Available)
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
(Available)
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?
Finding:
Denies past history of stomach cancer
(Available)
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 stomach cancer will allow her to describe any historical concerns or problems she’s had.
Example Question:
Have you ever had stomach cancer?
Finding:
Denies past history of liver disease
(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 liver disease will allow her to describe any historical concerns or problems she’s had.
Example Question:
Have you ever been diagnosed with liver disease?
Finding:
Denies past history of kidney disease
(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 had any kidney diseases will allow her to describe any historical concerns or problems she’s had.
Example Question:
Have you ever had any kidney diseases?
Finding:
Denies past history of bladder disease
(Available)
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 had a bladder disease will allow her to describe any historical concerns or problems she’s had.
Example Question:
Have you ever had a bladder disease?
Finding:
Asked about typical bowel movements
Finding:
Reports bowel movement every 2 days
(Found)
Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.
Example Question:
How often do you have a bowel movement?
Finding:
Denies pain during bowel movements
(Available)
Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.
Example Question:
Do you have any pain with your bowel movements?
Finding:
Denies bloody or tarry stools
(Available)
Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms.
Example Question:
Do you have dark colored stools?
Finding:
Denies mucus in stool
(Available)
Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms.
Example Question:
Do you notice mucus in your stools?
Finding:
Describes consistency of bowel movements
(Available)
Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.
Example Question:
Are your bowel movements consistent?
Finding:
Asked about typical urination
Finding:
Reports increased urination
(Found)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina’s symptoms.
Example Question:
Have you been urinating more than usual?
Finding:
Reports urine is a clear or light-yellow color
(Available)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what color her urine is can help you to determine the cause of Tina’s symptoms.
Example Question:
What color is your urine?
Finding:
Reports nocturia
(Available)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina’s symptoms.
Example Question:
Have you had to wake up to urinate?
Finding:
Denies pain during urination
(Available)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if it is painful when she urinates can help you to determine the cause of Tina’s symptoms.
Example Question:
Is it painful when you urinate?
Finding:
Describes urine character as normal
(Available)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what her urine looks like can help you to determine the cause of Tina’s symptoms.
Example Question:
What does your urine look like?
Finding:
Denies pink or bloody urine
(Available)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine is ever red can help you to determine the cause of Tina’s symptoms.
Example Question:
Is your urine ever red?
Finding:
Denies incontinence
(Available)
Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she ever has trouble holding her urine in can help you to determine the cause of Tina’s symptoms.
Example Question:
Do you ever have trouble holding your urine in?
Finding:
Asked about menstruation and sexual activity
Finding:
LMP was 3 weeks ago
(Available)
Pro Tip: Gynecologic disorders appear to be more common in people with IBS. Soliciting information about Tina’s menstrual patterns can indicate whether her menstrual patterns are normal.
Example Question:
When was your last menstrual period?
Finding:
Denies sexual activity
(Found)
Pro Tip: Some sexually active people with IBD report pain and bloating during sex. Asking Tina if she is sexually active can help you to determine the extent of her gastrointestinal symptoms.
Example Question:
Are you currently sexually active?
Social History
Finding:
Asked about most recent meal
Finding:
Most recent meal was breakfast this morning
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina when she most recently ate will illustrate her dietary recent patterns.
Example Question:
When was your most recent meal?
Finding:
Most recent meal was toast with butter and honey and orange juice
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she ate for breakfast will indicate how she has been eating recently.
Example Question:
What did you eat for breakfast?
Finding:
Asked 24-hour diet recall
Finding:
Yesterday’s breakfast was cereal
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for breakfast yesterday will illustrate her recent dietary patterns.
Example Question:
What did you have for breakfast yesterday?
Finding:
Yesterday’s lunch was pizza
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for lunch yesterday will illustrate her recent dietary patterns.
Example Question:
What did you have for lunch yesterday?
Finding:
Yesterday’s dinner was a baked potato
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for dinner yesterday will illustrate her recent dietary patterns.
Example Question:
What did you have for dinner yesterday?
Finding:
Asked about typical diet
Finding:
Reports typical intake is 3 meals a day plus snacks
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many means she typically eats in a day will illustrate her recent dietary patterns.
Example Question:
How many meals do you eat in a typical day?
Finding:
Typical breakfast is cereal, bread, or a muffin
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns.
Example Question:
What is your typical breakfast?
Finding:
Typical lunch is a sandwich and chips
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns.
Example Question:
What is your typical lunch?
Finding:
Typical dinner is chicken, a vegetable or potatoes, and bread
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns.
Example Question:
What is your typical dinner?
Finding:
Reports fast food intake 3 times a week
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how often she eats fast food will illustrate her recent dietary patterns.
Example Question:
How often do you eat fast food?
Finding:
Typical snack is pretzels, French fries, crackers or chips
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns.
Example Question:
What is a typical snack for you?
Finding:
Asked about typical beverages
Finding:
Last alcoholic drink was 2 weeks ago
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina when she last had an alcoholic drink will illustrate her recent dietary patterns.
Example Question:
When did you last have an alcoholic drink?
Finding:
Typical alcohol frequency is 2 – 3 times a month
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many drinks she typically has in a month will illustrate her recent dietary patterns.
Example Question:
How many times a month do you drink alcohol?
Finding:
Typical alcohol intake is 2 – 3 drinks at a time
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many alcoholic drinks she typically has at a time will illustrate her recent dietary patterns.
Example Question:
How many alcoholic drinks do you typically have at one time?
Finding:
Reports that alcohol intake bothered her stomach
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if the alcohol makes her stomach pain worse will indicate whether alcohol is causing some of her GI symptoms.
Example Question:
Does alcohol make your stomach pain worse?
Finding:
Reports drinking soda
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if she drinks soda will illustrate her recent dietary patterns.
Example Question:
Do you drink soda?
Finding:
Reports drinking 3 – 4 diet cokes a day
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many diet cokes she drinks a day will illustrate her recent dietary patterns.
Example Question:
How many diet cokes do you drink in a day?
Finding:
Reports that she hasn’t noticed a connection between soda intake and pain
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if the diet coke makes her stomach pain worse will indicate whether diet coke is causing some of her GI symptoms.
Example Question:
Does the diet coke make your stomach pain worse?
Finding:
Reports drinking 6 – 8 glasses of water a day
(Available)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many glasses of water she has a day will indicate her current patterns of diet and consumption.
Example Question:
How many glasses of water do you drink each day?
Finding:
Asked about recent dietary and life experiences
Finding:
Denies recent travel
(Found)
Pro Tip: Recent dietary or new life experiences can result in digestive problems. Asking Tina if she’s traveled recently might point to something new that is triggering digestive problems for Tina.
Example Question:
Have you traveled recently?
Finding:
Denies food poisoning
(Available)
Pro Tip: Recent dietary or new life experiences can result in digestive problems. Asking Tina if she thinks she could have food poisoning might indicate what’s triggering Tina’s digestive problems.
Example Question:
Do you think you could have food poisoning?
Finding:
Asked about substance use
Finding:
Denies illicit drug use
(Available)
Pro Tip: Drug use can cause damage to the cells of the digestive tract and inhibit the secretion enzymes needed for digestion. Asking Tina if she currently uses and illicit drugs might indicate whether drug use is causing problems for her digestion.
Example Question:
Do you currently use any recreational drugs?
Finding:
Denies cigarette smoking
(Found)
Pro Tip: Smoking or inhaling substances can have adverse effects on the digestive system. Asking Tina if she currently smokes can help you to discern whether smoking was a factor in Tina’s recent digestive problems.
Example Question:
Do you smoke cigarettes?
Social Determinants of Health
Finding:
Asked about food access
Finding:
Reports living near grocery store
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
How far away is the grocery store from where you live?
Finding:
Reports access to fresh foods
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have access to fresh produce?
Review of Systems
Finding:
Asked about general symptoms
Finding:
Denies fever
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fever, details the way her individual symptoms and pain manifest.
Example Question:
Have you had any fever recently?
Finding:
Denies chills
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest.
Example Question:
Have you been feeling chills?
Finding:
Denies fatigue
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest.
Example Question:
Have you been fatigued?
Finding:
Denies night sweats
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest.
Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for mental health
Finding:
Reports occasional feelings of anxiety
(Available)
Pro Tip: Anxiety can manifest in symptoms like heartburn or acid reflux. Asking Tina if she’s experienced anxiety would suggest a cyclical relationship between her physical symptoms and anxiety.
Example Question:
Have you been experiencing anxiety?
Finding:
Reports feelings of stress
(Available)
Pro Tip: Anxiety can manifest in symptoms like heartburn or acid reflux. Asking Tina about her recent stress levels would suggest a cyclical relationship between her physical symptoms and anxiety.
Example Question:
How is your recent stress level?
Finding:
Asked about review of systems for gastrointestinal
Finding:
Denies nausea
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest.
Example Question:
Have you had any nausea?
Finding:
Denies vomiting
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vomiting, details the way her individual symptoms and pain manifest.
Example Question:
Have you been vomitting?
Finding:
Denies diarrhea
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like diarrhea, details the way her individual symptoms and pain manifest.
Example Question:
Have you had any diarrhea?
Finding:
Denies constipation
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like constipation, details the way her individual symptoms and pain manifest.
Example Question:
Have you been constipated?
Finding:
Denies flatus
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like gas, details the way her individual symptoms and pain manifest.
Example Question:
Have you had gas?
Finding:
Denies bloating
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like feeling bloated, details the way her individual symptoms and pain manifest.
Example Question:
Have you felt bloated?
Finding:
Asked about review of systems for respiratory
Finding:
Denies sore throat
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like throat pain, details the way her individual symptoms and pain manifest.
Example Question:
Do you have any throat pain?
Finding:
Denies coughing
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like coughing, details the way her individual symptoms and pain manifest.
Example Question:
Have you been coughing?
Finding:
Denies dysphagia
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty swallowing, details the way her individual symptoms and pain manifest.
Example Question:
Do you have difficulty swallowing?
Finding:
Denies difficulty breathing
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty breathing, details the way her individual symptoms and pain manifest.
Example Question:
Have you had difficulty breathing?
Finding:
Denies chest pain
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like chest pain, details the way her individual symptoms and pain manifest.
Example Question:
Have you had any chest pain?
Finding:
Denies palpitations
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like palpitations, details the way her individual symptoms and pain manifest.
Example Question:
Have you had any palpitations?
Finding:
Denies change in sense of taste
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like change in her sense of taste, details the way her individual symptoms and pain manifest.
Example Question:
Has there been any change to your sense of taste?
Family History
Finding:
Asked about relevant family history
Finding:
Reports family history of colon cancer
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of colon cancer might reveal a predisposition to gastrointestinal issues.
Example Question:
Do you have a family history of colon cancer?
Finding:
Denies family history of GERD
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of GERD might reveal a predisposition to gastrointestinal issues.
Example Question:
Do you have a family history of GERD?
Finding:
Denies family history of IBS
(Found)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of irritable bowel syndrome might reveal a predisposition to gastrointestinal issues.
Example Question:
Do you have a family history of irritable bowel syndrome?
Finding:
Denies family history of cholecystitis
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of cholecystitis might reveal a predisposition to gastrointestinal issues.
Example Question:
Do you have a family history of cholecystitis?
Finding:
Denies family history of liver disease
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of liver disease might reveal a predisposition to gastrointestinal issues.
Example Question:
Do you have a family history of liver disease?
Finding:
Denies family history of kidney disease
(Available)
Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of kidney disease might reveal a predisposition to gastrointestinal issues.
Example Question:
Do you have a family history of kidney disease?
Finding:
Denies family history of bladder disease
Objective Data Collection: 18 of 18 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
Observations (1/1 point)
- No tenting
Symmetry (1/3 point)
- Symmetric
Contour (1/3 point)
- Protuberant
Appearance (1/3 point)
- Striae
- Excessive hair growth
Breath Sounds (1/3 point)
- Present in all areas
Adventitious Sounds (1/3 point)
- No adventitious sounds
Location (1/3 point)
- All areas clear
Heart Sounds (1/2 point)
- S1 and S2 audible
Extra Heart Sounds (1/2 point)
- No extra sounds
Sounds (1/2 point)
- Normoactive
Location Of Non Normoactive Bowel Sounds (1/2 point)
- All quadrants normoactive
Sound (1/1 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Right (1/2 point)
- No bruit
Left (1/2 point)
- No bruit
Observations (1/1 point)
- All areas generally tympanic
Patient Reaction (1/1 point)
- Did not react
Spleen (1/1 point)
- Tympany
Size (1/1 point)
- Between 6 and 12 cm
Tenderness (1/3 point)
- None reported
Location Of Tenderness (1/3 point)
- No quadrants tender
Observations (1/3 point)
- No additional observations
Presence Of Unexpected Mass (1/2 point)
- No palpable mass
Location Of Mass (1/2 point)
- No palpable mass
Detection (1/1 point)
- Palpable
Detection (1/1 point)
- Not palpable
Right (1/2 point)
- Not palpable
Left (1/2 point)
- Not palpable
Education & Empathy : 3 of 4 (75.0%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
| Description: Tina describes the symptoms that have been bothering her. | ||
| What brings you here today? | Question 05:00 AM EDT |
|
| I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me. | ||
| I am sorry for that | Empathize 05:00 AM EDT |
|
| I appreciate you telling me that. | ||
| Model Statement: “I’m sorry to hear you’re having stomach pain. I’m glad you came in to see me. Stomach pain can be caused by several different things, so I will ask you questions and we’ll see if we can determine what’s causing yours.” |
| Description: Tina describes her medication regimen, including antacids for her stomach pain. | ||
| Do you use any medication? | Question 05:11 AM EDT |
|
| I have a daily inhaler. And I’ve been taking antacid chews sometimes for my stomach, too. | ||
| How often do you take antacids? | Question 05:11 AM EDT |
|
| I take them every few days. Just if the heartburn gets bad. | ||
| Antacids actually works best when you take them before a meal | Educate 05:14 AM EDT |
|
| That makes sense. | ||
| Model Statement: “Thank you for letting me know that you’re using antacids in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.” |
| Description: Tina’s diet contains high levels of carbohydrates, which is not recommended for a person with diabetes. | ||
| Which foods do you take? | Question 05:15 AM EDT |
|
| Oh, I know vegetables are healthy. Anything with vegetables is going to be healthier. I mean, an extra-healthy meal at our house would be baked chicken and some green beans. I make that like once a week. | ||
| What is you typical diet? (Clarified to: What do you eat in an average day?) | Question 05:15 AM EDT |
|
| Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to: what I typically eat in a day) | ||
| Your meal has a high level of carbohydrate which is not recommended for diabetes patients. | Educate 05:16 AM EDT |
|
| Sure, I think I understand what you mean. | ||
| Model Statement: “It sounds like you’re eating quite a few carbohydrates, which can be unhealthy for people with diabetes. Carbohydrates are found in things like pizza crust, potatoes, bread, and juice. Let’s talk about eating foods with fewer carbohydrates.” |
| Description: Tina drinks Diet Coke every day, which is acidic and could irritate her symptoms. | ||
| Model Statement: “Some forms of stomach pain can be irritated by acidic drinks or foods. Drinking less soda and more water could relieve some of your stomach pain.” |
Documentation / Electronic Health Record
Document: Provider Notes
| Student Documentation | Model Documentation |
| Subjective
Ms. Jones is 28 y/o African American woman who presents to the clinic with complaints of upper stomach pain after eating. The pain started a month ago. She experiences the pain daily but is worse 3-4 times per week. Pain is 5/10 and is located in her upper stomach. She says it feels like a heartburn but can be sharper. It increases with consumption of food which causes increased burning after meals. Has no recent changes in meals. She has increased water intake. She takes a muffin or pumpkin break for breakfast. Dinner is homemade meal of a meat and vegerable, snacks are French fries. She denies coffee intake. |
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Pain is a 5/10 and is located in her upper stomach. She describes it “kind of like heartburn” but states that it can be sharper. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. She does notice that she has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “every few days” with an over the counter antacid with some relief. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink diet cola on a regular basis. She denies use of tobacco and illicit drugs. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. She does not exercise. Review of Systems: General: Denies changes in weight and general fatigue. She denies fevers, chills, and night sweats. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, and constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequency. Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen. |
| Objective
Ms. Jones is 28 y/o African American woman and is no acute distress. She is alert and oriented. -Abdominal: Soft and protuberant without scars or skin lesions, skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants No CVA tenderness – Cardiovascular: Regular rate and thythm, S1 and S2 present, no murmurs, rubs, gallops. Respiratory: Chest is symmetrical. Lung sound clear to auscultation anteriorly and posteriorly without wheezes, crackles or cough. |
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. No bruits with auscultation over abdominal aorta. No femoral, iliac, or renal bruits. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. |
| Assessment
GERD |
Gastroesophageal reflux disease without evidence of esophagitis |
| Plan
Educate the patient on lifestyle changes to help in weight loss by enganging in daily physical activity. Have a confortable place to sleep and reduce symptoms. Encourage to eat smaller meals and avoid eating 2-3 hours before bedtime. Educate on dietary reduction in fat to decrease symptoms Give famotidine 10 mg by mouth twice daily for two weeks Follow up may include tests such at H pylori and |
Educate on lifestyle changes including weight loss, engagement in daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcohol, and spicy foods. • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduction. • Encourage to eat smaller meals and to avoid eating 2-3 hours before bedtime. • Educate on dietary reduction in fat to decrease symptoms. • Trial of famotidine 10 mg by mouth twice daily for two weeks. If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, follow up for subsequent recommendations and consider testing for helicobacter pylori, trial of a proton pump inhibitor, or upper endoscopy. • Educate on when to seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain. • Return to clinic in two weeks for evaluation and follow up. |
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