Nolan Young – I-Human
Patient and Encounter
● Patient: Nolan Young
● Age: 60-year-old male
● Height: 6'2"
● Weight: 204 lb
● Reason for encounter: Belly/abdominal pain
● Setting: Outpatient primary-care clinic
● Current complaint: Intermittent abdominal pain for approximately 6–8 months that has become
more consistent over the past few months
● Location: Primarily epigastric region
● Quality: Burning with occasional stabbing sensation
● Timing: Typically begins approximately 1 hour after eating
● Radiation: Pain can radiate through to the back
● Associated symptoms: Fullness/bloating and increased belching
● Sleep: Pain has awakened him from sleep
● Self-treatment: Has been taking antacids without relief
● Alcohol: Reports drinking beer, including before bedtime on at least one occasion
History
General
● How can I help you today?
● When did the abdominal pain begin?
● Has the pain changed in frequency or severity?
● Is the pain constant or intermittent?
● How severe is the pain from 0–10?
● Has anything made the pain better or worse?
● Does the pain interfere with sleep or daily activities?
Abdominal Pain
● Where exactly is the pain located?
● Does the pain radiate anywhere?
● How would you describe the pain?
● Is it burning, stabbing, cramping, aching, or pressure?
● When does the pain occur?
● How long does each episode last?
● Does eating make the pain better or worse?
● How soon after eating does the pain begin?
● Does the pain improve when you stop eating?
, ● Does the pain occur at night?
● Does alcohol affect the pain?
● Does lying down affect the pain?
GI Symptoms
● Any nausea?
● Any vomiting?
● Any hematemesis or vomiting blood?
● Any heartburn or acid reflux?
● Any difficulty swallowing?
● Any painful swallowing?
● Any excessive belching?
● Any abdominal bloating or fullness?
● Any diarrhea?
● Any constipation?
● Any change in stool color?
● Have you noticed black/tarry stools?
● Any blood in the stool?
● Any unexplained weight loss?
● Any loss of appetite?
Past History
● History of peptic ulcer disease?
● History of GERD?
● Previous H. pylori infection?
● Previous gastrointestinal bleeding?
● Previous abdominal surgery?
● History of liver or pancreatic disease?
● Any previous endoscopy or colonoscopy?
Medications/Allergies
● What prescription medications are you taking?
● What OTC medications are you taking?
● How often do you take NSAIDs such as ibuprofen or naproxen?
● Do you take aspirin?
● Have you recently taken antibiotics?
● What antacids have you tried?
● Any vitamins or supplements?
● Any medication allergies?
Social History
Patient and Encounter
● Patient: Nolan Young
● Age: 60-year-old male
● Height: 6'2"
● Weight: 204 lb
● Reason for encounter: Belly/abdominal pain
● Setting: Outpatient primary-care clinic
● Current complaint: Intermittent abdominal pain for approximately 6–8 months that has become
more consistent over the past few months
● Location: Primarily epigastric region
● Quality: Burning with occasional stabbing sensation
● Timing: Typically begins approximately 1 hour after eating
● Radiation: Pain can radiate through to the back
● Associated symptoms: Fullness/bloating and increased belching
● Sleep: Pain has awakened him from sleep
● Self-treatment: Has been taking antacids without relief
● Alcohol: Reports drinking beer, including before bedtime on at least one occasion
History
General
● How can I help you today?
● When did the abdominal pain begin?
● Has the pain changed in frequency or severity?
● Is the pain constant or intermittent?
● How severe is the pain from 0–10?
● Has anything made the pain better or worse?
● Does the pain interfere with sleep or daily activities?
Abdominal Pain
● Where exactly is the pain located?
● Does the pain radiate anywhere?
● How would you describe the pain?
● Is it burning, stabbing, cramping, aching, or pressure?
● When does the pain occur?
● How long does each episode last?
● Does eating make the pain better or worse?
● How soon after eating does the pain begin?
● Does the pain improve when you stop eating?
, ● Does the pain occur at night?
● Does alcohol affect the pain?
● Does lying down affect the pain?
GI Symptoms
● Any nausea?
● Any vomiting?
● Any hematemesis or vomiting blood?
● Any heartburn or acid reflux?
● Any difficulty swallowing?
● Any painful swallowing?
● Any excessive belching?
● Any abdominal bloating or fullness?
● Any diarrhea?
● Any constipation?
● Any change in stool color?
● Have you noticed black/tarry stools?
● Any blood in the stool?
● Any unexplained weight loss?
● Any loss of appetite?
Past History
● History of peptic ulcer disease?
● History of GERD?
● Previous H. pylori infection?
● Previous gastrointestinal bleeding?
● Previous abdominal surgery?
● History of liver or pancreatic disease?
● Any previous endoscopy or colonoscopy?
Medications/Allergies
● What prescription medications are you taking?
● What OTC medications are you taking?
● How often do you take NSAIDs such as ibuprofen or naproxen?
● Do you take aspirin?
● Have you recently taken antibiotics?
● What antacids have you tried?
● Any vitamins or supplements?
● Any medication allergies?
Social History
