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Reason for Encounter
Start with open-ended patient-centric questions.
Asked X Not asked.
Graded Approach Question
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How can I help you today?
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Do you ever feel/have a problem with lightheadedness?
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Is there any blood in your stools or with your bowel movement?
Have you gained or lost weight unintentionally, despite normal appetite and exercise?
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Do you have any other symptoms or concerns we should discuss?
Response
I'm having really bad belly pain. Can't take it anymore so I came in.
Yes, I do sometimes, a bit now in fact.
I haven't seen anything red like blood.
I have lost some weight recently... like over the past few months. I'm not one to exercise, but I have been doing more stuff with my buddies lately. I just don't have much of an appetite, so I guess that's not totally normal. Some days I just don't feel much like eating much. That's probably why I've lost some weight lately.
Yeah, I've been feeling really tired. And if that's not enough, my heartburn also has been worse than usual.
Information Obtained Clinic Notes
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