Nurs 6512 Week 6 Assignment 1 1. Analyze the subjective portion of the note. List additional information that should be included in the documentation. SUBJECTIVE: CC : “My stomach hurts, I have diarrhea, and nothing seems to help.” HPI : JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards. PMH : HTN, Diabetes, hx of GI bleed 4 years ago Medications : Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs Allergies : NKDA FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD Social : Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys) Additional information that should be included in the subjective documentation would be in the history and physical information section. The provider should note the character of the pain such as dull, sharp, cramping, aching, etc. Also, the provider should ask JR about any precipitating or aggravating factors such as pain after eating or before, pain with lying down or bending, pain with movement, etc. The characteristic, consistency, color, and frequency of his diarrhea should also be noted here. JR states he has not taken any medicine, but the provider should still ask about any relieving factors or treatments that he has tried in the past 3 days. It would also be beneficial to know if this pain has occurred before in the past to assess if this is acute, chronic, or episodic pain. Other pertinent information to be included would be to ask if JR has had any recent travel out of the United States or has eaten anything that could have been spoiled or contaminated in the last days leading up to the occurrence. It would be pertinent to assess for involuntary weight loss that could indicate a neoplasm (Dains, Baumann, Scheibel, 2016). The provider should also ask if his wife and children are experiencing any of the same symptoms. It would also be helpful to know how his blood sugars have been in the last few days. Also, in the subjective data portion it is essential to add the Review of Systems. The ROS is an inventory of specific body systems designed to document any symptoms the patient may be having or had in the past (Sullivan, 2019). In the social history portion, more questions regarding his diet such as a 24-hr diet recall would be beneficial for diagnosis.
- Summer '15
- Gastroenterology, Dains