Subjective Data Collection - correct answer Patient Data
Chief Complaint - correct answer Empathize
Orientation - correct answer Do you know where you are?
History of Present Illness - correct answer How long have you been having
discomfort? Has the pain changed at all? Where is your pain located? Do you have
any pain on your sides? Does your pain feel dull? Do you have abdominal
cramping? How severe is your pain?
Asked about non-pharmacological relieving factors - correct answer Are you
taking pain medication? Are you taking laxatives?
Asked about aggravating factors - correct answer Does eating make your
abdominal pain worse? Do you experience abdominal pain with activity?
Asked about impact of pain on daily life - correct answer Are you able to perform
all of your usual daily activities? What is your energy level?
Followed up on constipation - correct answer Do you have constipation? When
were you last constipated? Have you tried anything to treat the constipation?
Followed up about diarrhea - correct answer Have you had diarrhea recently?
How long did the diarrhea last? What color was the diarrhea?
Asked about substances in stool - correct answer Do you have mucus in your
stool? Do you have blood in your stool?
Asked about urination - correct answer How often do you urinate? What color is
your urine? Do you have blood in your urine?
Asked about fluid intake - correct answer What is your typical fluid intake a day?
Do you drink caffeinated drinks?
PAST MEDICAL HISTORY - correct answer How often do you have a bowel
movement? What does your stool look like?
Asked about allergies - correct answer Are you allergic to latex? Are you allergic
to any medications? Do you have any food allergies?
Asked about pre-existing health conditions - correct answer Do you have any pre-
existing health conditions? When were you diagnosed with high blood pressure?
Asked about relevant history of surgery - correct answer Have you been
pregnant? What happened to your third pregnancy?
HOME MEDICATIONS - correct answer Do you take medications? What is the
prescribed dosage for the medication? When do you take your high blood
pressure medication?
Asked about access to healthcare - correct answer Do you go to your annual
check-ups? When was your last pap smear? What is your activity level? Do you
have intercourse? Have you been tested for STDs?
Asked about family and support system - correct answer Do you live alone? Do
you have a strong support system?
Asked about diet - correct answer When was your last meal? How many meals do
you have in a day? What is your typical breakfast? What is your typical lunch?
What is your typical dinner?
Asked about fiber intake - correct answer Do you incorporate fiber in your diet?
Fiber is essential to the diet. Adults should aim for around 28 grams of fiber per
day from fruits, vegetables, and whole grains.
Asked about substance use - correct answer Do you smoke marijuana? Do you
smoke cigarettes? Do you drink alcohol?
Followed up about alcohol consumption - correct answer How often do you drink
alcohol? How many alcoholic drinks do you have in one sitting?
Asked about experience of abuse - correct answer Have you experienced any
abuse?
Review of Systems - Constitutional Health - correct answer Have you noticed
recent changes in weight? Do you have fever, chills, night sweats, or feel
exhausted?
Review of Systems - Gastrointestinal - correct answer Do you feel bloated, gassy,
have an appetite, experience nausea/vomiting, or have a history of
gastrointestinal disorders?
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