Nursing and Health Examples

Burning Sensation In Stomach Walls Patient History

This example provides a comprehensive patient history focusing on a burning sensation in the stomach walls. It details the patient's subjective complaints, medical background, medication history, social factors, and a thorough physical examination. The documentation follows standard nursing practices for accurate and effective patient care, offering a model for students and professionals in health sciences. It highlights the importance of precise symptom description and systematic data collection in diagnosing and managing gastrointestinal issues.

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Key considerations

A structured approach to patient history taking ensures comprehensive data collection, vital for accurate diagnosis and care planning.

Detailed symptom description, including character, location, timing, and modifying factors (OLDCARTS), is critical for understanding patient complaints like abdominal burning.

Integrating subjective patient reports with objective physical findings and a thorough review of medical, family, and social history provides a holistic view of the patient's health.

Professional, objective, and concise documentation is essential for effective communication among healthcare team members and for legal and ethical record-keeping.

Assignment brief

You are a registered nurse documenting a new patient presenting with a chief complaint of a burning sensation in their stomach walls. Create a detailed patient history, including subjective data (patient's own words), objective data (your observations and measurements), past medical history, family history, social history, review of systems, and a focused physical examination relevant to gastrointestinal complaints. Ensure the documentation is clear, concise, and follows standard nursing documentation practices.

Reference example

Patient Name: Eleanor Vance Date of Birth: 03/15/1958 (Age 66) MRN: 7890123 Date of Admission: 10/26/2024 Time: 14:30 Admitting Nurse: J. Carter, RN

Chief Complaint (CC): "I've had this burning, gnawing pain in my stomach for weeks, and it's getting worse."

History of Present Illness (HPI): Ms. Vance is a 66-year-old female presenting with a chief complaint of a burning sensation in her epigastric region, which she describes as a "gnawing" or "gnawing ache" that has been present intermittently for approximately six weeks. The pain is located primarily in the upper central abdomen, sometimes radiating slightly to the back, but not into the chest or shoulders. She rates the pain on average as a 5/10, but it has peaked at an 8/10, particularly after meals or at night. The burning sensation is most pronounced about 1-2 hours after eating and often wakes her from sleep between 2:00 AM and 3:00 AM. She reports that the pain is temporarily relieved by antacids (Tums), usually for about 30-60 minutes, but it returns. She denies any nausea or vomiting associated with the pain, but reports occasional bloating and a feeling of early satiety. She has noticed a slight decrease in appetite due to the discomfort. She denies any recent changes in bowel habits, such as diarrhea or constipation, and her stools have remained their usual brown color without any visible blood. She denies any fever, chills, or unintentional weight loss.

Past Medical History (PMH):

Hypertension (HTN): Diagnosed 15 years ago. Managed with medication. Last BP reading at home was 135/85 mmHg two days ago.
Hyperlipidemia (HLD): Diagnosed 10 years ago. Managed with medication.
Osteoarthritis (OA): Affecting knees and hands. Manages with over-the-counter pain relievers as needed.
Peptic Ulcer Disease (PUD): Diagnosed approximately 20 years ago, treated successfully with medication. No recurrence reported until current symptoms.
Appendectomy: Age 17.

Past Surgical History (PSH):

Appendectomy (1975)
Cholecystectomy (laparoscopic, 2010)

Medications:

Lisinopril 20 mg PO daily (for HTN)
Atorvastatin 40 mg PO daily (for HLD)
Tums (Calcium Carbonate) 1000 mg PO PRN for heartburn/indigestion (takes 2 tablets 2-3 times per week, last dose this morning)
Ibuprofen 200 mg PO PRN for OA pain (takes occasionally, last dose 3 days ago)

Allergies:

Penicillin (rash)
No known food allergies.

Family History (FH):

Mother: Died at 82 from stroke. History of HTN and diabetes.
Father: Died at 70 from myocardial infarction. History of HTN and HLD.
Siblings: One brother, alive and well. No significant chronic illnesses reported.
Children: Two adult children, no significant chronic illnesses reported.

Social History (SH):

Occupation: Retired elementary school teacher.
Living Situation: Lives with her husband in a single-family home.
Diet: Reports trying to eat a balanced diet but admits to enjoying spicy foods and coffee, which she suspects might exacerbate her symptoms. Drinks 2-3 cups of coffee daily. Limited alcohol intake (1-2 glasses of wine per week).
Smoking: Denies current smoking. Smoked 1 pack per day for 10 years (quit at age 30).
Illicit Drug Use: Denies.
Exercise: Walks 30 minutes 3-4 times per week.
Stressors: Reports moderate stress related to caring for her elderly mother, but denies acute stressors.

Review of Systems (ROS):

General: Denies fever, chills, fatigue, or recent weight loss.
HEENT: Denies headache, vision changes, hearing loss, sore throat, or nasal congestion.
Cardiovascular: Denies chest pain, palpitations, or edema.
Respiratory: Denies cough, shortness of breath, or wheezing.
Gastrointestinal: Positive for epigastric burning/gnawing pain, bloating, early satiety. Denies nausea, vomiting, diarrhea, constipation, melena, or hematochezia. Reports occasional relief with antacids.
Genitourinary: Denies dysuria, frequency, or urgency.
Musculoskeletal: Positive for OA pain in knees and hands, managed PRN. Denies other joint pain or swelling.
Skin: Denies rashes or lesions.
Neurological: Denies dizziness, syncope, or focal weakness.
Psychiatric: Denies anxiety or depression.

Physical Examination:

Vital Signs: Temp 98.6°F (37.0°C), HR 78 bpm (regular), RR 16 breaths/min, BP 130/80 mmHg (left arm, sitting), SpO2 98% on room air.
General Appearance: Well-developed, well-nourished female in no acute distress. Appears comfortable at rest.
Abdomen:
Inspection: Abdomen is flat, symmetrical, no visible scars from previous surgery (appendectomy, cholecystectomy). No distension or masses noted.
Auscultation: Bowel sounds are normoactive in all four quadrants (5-30 sounds/min). No bruits heard.
Percussion: Tympanic throughout all quadrants. No tenderness elicited on percussion.
Palpation: Soft. Mild tenderness to deep palpation in the epigastric region, without guarding or rebound tenderness. No hepatosplenomegaly or masses palpated.
Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, or gallops.
Respiratory: Lungs clear to auscultation bilaterally, no adventitious sounds.

Assessment: Ms. Vance presents with symptoms suggestive of an upper gastrointestinal disorder, most likely peptic ulcer disease or significant gastritis, given the chronicity, character of pain (burning, gnawing), timing (postprandial, nocturnal), and partial relief with antacids. Her history of PUD is a significant factor. Hypertension and hyperlipidemia are stable and managed. No acute cardiopulmonary or other systemic issues identified on ROS and physical exam.

Plan:

Further diagnostic workup: Schedule for upper endoscopy (EGD) to visualize the esophagus, stomach, and duodenum, and to obtain biopsies if indicated. Discussed risks/benefits/alternatives with patient.
Medication adjustment: Continue current medications for HTN and HLD. Consider initiating a proton pump inhibitor (PPI) such as omeprazole 20 mg daily for symptom management pending EGD results, and discuss lifestyle modifications.
Lifestyle modifications: Advise patient to avoid trigger foods (spicy foods, caffeine, alcohol) and to eat smaller, more frequent meals. Advise against NSAID use unless absolutely necessary and to discuss with physician if pain management is needed.
Patient Education: Educated patient on potential causes of her symptoms, the rationale for EGD, and the importance of medication adherence and lifestyle changes. Provided information on signs/symptoms that warrant immediate medical attention (e.g., severe abdominal pain, vomiting blood, black tarry stools).
Follow-up: Schedule follow-up appointment to review EGD results and adjust treatment plan as needed.

Signature: J. Carter, RN License # R123456

Understanding Patient History Documentation in Nursing

Accurate and thorough patient history documentation is fundamental to effective nursing practice. It forms the bedrock upon which clinical judgments are made, treatment plans are developed, and patient care is delivered. A well-constructed patient history allows healthcare professionals to understand the patient's current health status, identify potential risks, and establish a baseline for monitoring progress. This example focuses on a common patient complaint—a burning sensation in the stomach walls—and demonstrates how a nurse would systematically gather and record relevant information.

Structure of the Patient History Example

The provided patient history follows a standard, logical structure commonly used in healthcare settings. This organization ensures that all critical areas are covered systematically, making the information easily accessible and understandable for other members of the healthcare team. The sections flow from the patient's immediate concerns to their broader medical and social context.

Demographic and Identifying Information: Basic patient details like name, age, and medical record number.
Chief Complaint (CC): The primary reason the patient is seeking care, often in their own words.
History of Present Illness (HPI): A detailed narrative of the chief complaint, including onset, location, duration, characteristics, aggravating/alleviating factors, radiation, timing, and severity (often remembered by the mnemonic OLDCARTS).
Past Medical History (PMH): Significant chronic and acute illnesses the patient has experienced.
Past Surgical History (PSH): Previous surgical procedures.
Medications: A comprehensive list of current medications, including dosage, route, and frequency.
Allergies: Known allergies to medications, food, or environmental factors.
Family History (FH): Health status of immediate family members, noting hereditary conditions.
Social History (SH): Lifestyle factors such as occupation, living situation, diet, substance use, and stress levels.
Review of Systems (ROS): A systematic head-to-toe inquiry about symptoms in various body systems.
Physical Examination: Objective findings from the nurse's physical assessment.
Assessment: The nurse's clinical judgment based on the gathered information.
Plan: The proposed course of action for diagnosis, treatment, and follow-up.

Analysis: Thesis or Claim

The implicit thesis of this patient history document is that a systematic and comprehensive approach to data collection is essential for accurate clinical assessment and effective patient management. The document aims to demonstrate how detailed subjective and objective information, combined with a thorough review of the patient's background, leads to a well-reasoned clinical assessment and a targeted plan of care. The specific focus on the burning sensation in the stomach walls serves as a case study for applying these principles to a common gastrointestinal complaint.

Analysis: Evidence and Detail

The strength of this example lies in its detailed and specific evidence. Instead of generic statements, it provides concrete information: 'burning, gnawing pain,' 'epigastric region,' 'radiating slightly to the back,' '5/10, but it has peaked at an 8/10,' '1-2 hours after eating,' 'wakes her from sleep between 2:00 AM and 3:00 AM.' This level of detail, often guided by mnemonics like OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Radiation, Timing, Severity), is crucial for differential diagnosis. The inclusion of specific medication names (Lisinopril, Atorvastatin, Tums, Ibuprofen) and dosages, as well as the patient's history of PUD and appendectomy, adds further layers of relevant data. The physical examination findings are also specific, noting 'mild tenderness to deep palpation in the epigastric region' but the absence of 'guarding or rebound tenderness,' which helps rule out more acute surgical conditions.

Analysis: Organization and Flow

The document's organization is a significant strength. It moves logically from the patient's immediate complaint (CC, HPI) to their broader health context (PMH, PSH, FH, SH) and then to the nurse's objective findings (Physical Exam). This structured approach ensures that no critical information is missed and that the data is presented in a way that facilitates understanding. The Review of Systems (ROS) acts as a bridge, systematically exploring other potential issues that might be related or unrelated to the chief complaint. The final Assessment and Plan sections directly synthesize the preceding information, demonstrating how the data informs clinical decision-making. The use of clear headings for each section enhances readability and navigability.

Analysis: Tone and Professionalism

The tone is objective, professional, and clinical. It avoids subjective language or emotional commentary, focusing solely on factual reporting and clinical observations. Phrases like "Patient reports," "Denies," "Positive for," and objective measurements (e.g., vital signs, pain scale ratings) contribute to this professional tone. The use of standard medical abbreviations (HTN, HLD, PUD, EGD, PPI, RN) is appropriate for a healthcare setting, assuming a shared understanding among professionals. The assessment and plan sections are concise and action-oriented, reflecting a professional approach to patient care.

Analysis: Revision Opportunities and Best Practices

While this example is strong, potential revision opportunities often arise in real-world documentation. For instance, the 'Social History' could be expanded to include more detail on diet composition (e.g., specific types of spicy foods, frequency of fatty meals) if it's deemed highly relevant to GI symptoms. The 'Review of Systems' is comprehensive but could be tailored further based on initial findings; for example, if the HPI strongly suggests a GI issue, the nurse might probe more deeply into GI-related ROS questions. In terms of best practices, ensuring all subjective statements are attributed to the patient (e.g., "Patient states," "Patient reports") is crucial. The plan section clearly outlines next steps, but in a live scenario, it would also include the patient's understanding and agreement with the plan. For educational purposes, explicitly stating the rationale behind certain questions or examination findings could further enhance learning, though this is typically omitted in actual patient charts for brevity.

Example: Documenting Patient's Description of Pain

Instead of writing 'Patient has stomach pain,' a more effective documentation would be: Patient reports a burning, gnawing sensation in the epigastric region, rated 5/10, worsening to 8/10 after meals and at night. Pain is partially relieved by Tums for 30-60 minutes. Denies radiation to chest or back. No associated nausea or vomiting. This detailed description provides crucial diagnostic information regarding the character, location, severity, timing, and modifying factors of the pain, which is far more valuable than a simple statement of pain presence.

Have I clearly stated the Chief Complaint in the patient's own words?
Is the History of Present Illness detailed, covering OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Radiation, Timing, Severity)?
Have I included all relevant Past Medical and Surgical History?
Is the current Medication list accurate and complete (dose, route, frequency)?
Are known Allergies clearly documented?
Does the Social History capture relevant lifestyle factors (diet, smoking, alcohol, stress)?
Has a systematic Review of Systems been performed and documented?
Are Physical Examination findings objective and specific?
Does the Assessment reflect a clinical judgment based on the gathered data?
Is the Plan clear, actionable, and appropriate for the assessment?

FAQs

What is the most important part of a patient history for gastrointestinal issues?

While all sections are important, the History of Present Illness (HPI) is particularly crucial for gastrointestinal complaints. Detailed information about the nature of the pain (burning, cramping, sharp), its location (epigastric, diffuse, lower quadrants), timing (related to meals, nocturnal), aggravating and alleviating factors (food, medications, position), and associated symptoms (nausea, vomiting, changes in bowel habits, bleeding) are key to narrowing down potential diagnoses like gastritis, PUD, GERD, or even more serious conditions.

How does the patient's past medical history influence the current assessment?

A patient's past medical history provides essential context. For example, Ms. Vance's history of Peptic Ulcer Disease (PUD) significantly increases the suspicion that her current burning sensation is a recurrence or complication of PUD. Similarly, a history of hypertension or hyperlipidemia might prompt consideration of cardiovascular causes for chest or epigastric pain, though in this case, the symptoms are more classic for GI issues. Knowing about previous surgeries can also be relevant, as adhesions or altered anatomy can sometimes contribute to current symptoms.

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