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?
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Available)
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
(Found)
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
(Available)
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
(Found)
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
(Found)
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
(Found)
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
(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 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
(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 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
(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 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
(Found)
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
(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 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
(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 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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(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 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
(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 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
(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 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
(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 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
(Found)
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
(Found)
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
(Available)
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
(Available)
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
(Found)
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
(Found)
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
(Found)
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.
Is this the question you were looking for? If so, place your order here to get started!
