NR511 Week 5 iHuman Mark Griffin

Pivotal

Concept

Addressed

Category

Question

Response

•

HPI

How can I help you today?

I’ve been having stomach pain, and I just hit my breaking point. I’m hoping you can figure out what is causing it and fix it.

•

HP!

Do you have any other symptoms or concerns we should discuss?

I have indigestion as well. And since you mentioned, I had some weird bowel movements and an episode of vomiting a couple of months ago, when this pain first started. Nothing else that I can think of.

•

PMH

Do you have any allergies?

Not that I know of.

• pulse interpretation

• pulse interpretation

•Performed Correctly

• respiration

• respiration

• Performed Correctly

• temperature

• temperature

• Performed Correctly

• SpO:

• Performed Correctly

Your Findings

Case Findings

• History of coffee-ground emesis

• Burning epigastric pain for several months, improved

• History of black, tarry stool

with eating.

• NSAID use

• History of coffee-ground emesis.

• Epigastric tenderness to palpitation

• History of black, tarry stool.

• Burning epigastric pain; improved with eating

• NSAID use.

• Moderate alcohol use

• Moderate alcohol use.

• 30-pack-year smoking history

• 30-pack-year smoking history.

• Normal cardiopulmonary results

• Epigastric tenderness to palpation.

• Other ROS remain unremarkable

• Additional PMH.

• Family history (FH).

• Additional SH.

• Medications/Allergies.

• ROS: Inquiry into constitutional or systemic symptoms.

• ROS: Inquiry into cardiopulmonary symptoms.

• Communication: Elicit the patient’s perspective.