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tina jones gastrointestinal shadow health subjective data

tina jones gastrointestinal shadow health subjective data

Nursing Experts

tina jones gastrointestinal shadow health subjective data

Subjective Data Collection: 29 of 31 (93.5%)

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

    (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 many times a week do you have abdominal pain?

  • 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

  • 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

    (Found)

    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

    (Found)

    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

    (Found)

    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

    (Available)

    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

    (Available)

    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

    (Found)

    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

    (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?
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