Week 3 I-Human – Edwin Jackson
1. How can I help you today? Yesterday, I threw up what looks like coffee or dirt. This
morning I threw up again, but this time with bright red blood in it too. That got me
scared.
2. A
...
Week 3 I-Human – Edwin Jackson
1. How can I help you today? Yesterday, I threw up what looks like coffee or dirt. This
morning I threw up again, but this time with bright red blood in it too. That got me
scared.
2. Any other symptoms or concerns we should discuss? I haven’t been able to hold anything
down since this started.
3. Do you have any pain anywhere? If so, Where? No.
4. When did your nausea/vomiting start? My nausea started a couple of days ago. The
vomiting started yesterday.
5. When was the last time you vomited blood or coffee grounds? Just before I came here.
6. How many episodes of vomiting blood or coffee grounds did you have? Well 6 or 7
yesterday and a couple a more today with the coffee grounds. Then today I saw blood
too. That’s when I thought I should come here.
7. How much blood did you see in your vomit (a teaspoon, cup, quart)? I don’t know. I’m
not good at estimating stuff like that, I don’t think it was a quart though.
8. What are the events surrounding the start of your nausea/vomiting? Nothing really
happened. It just started.
9. Does anything make your nausea/vomiting better or worse? Eating and drinking makes
the nausea worse, and I vomit shortly after that.
10. Do you have any pain or other symptoms associated with your nausea/vomiting? No pain.
11. Have you had nausea and vomiting like this before? Never!
12. How quickly does your nausea and vomiting come on? Pretty fast. I don’t want to be too
far from a bathroom.
13. Is there any pattern to your nausea and vomiting? I don’t really know. I do throw up if I
try to eat anything. Shortly after that. Would you call that a pattern?
14. Is anyone in your family also suffering with nausea and vomiting? No.
15. What treatments have you had for your nausea and vomiting? Nothing. I mean I haven’t
tried anything to settle my stomach. I hope you can help me. I feel horrible.
16. Tell me about any current or past medical problems? Well, I’ve had high blood pressure
for seven years. I think it is under control though. I have a bad liver from drinking too
much.
17. Have you had any recent acute or chronic infection? No.
18. Have you had a recent endoscopy, colonoscopy, or biopsy? No. I’ve never had an
endoscopy. I had that biopsy 2 years when they told me I have a bad liver. Was that it?
19. Have you ever had a colonoscopy? It was recommended when I turned 50. But I never
got around to doing it.
20. Have you been treated for blood clots? (have a history of thrombolytic or anticoagulation
therapy)? No.
21. Any previous medical, surgical, or dental procedures? I had a stomach scan and biopsy
two years ago. That’s what confirmed my bad liver. Also had my appendix taken out in
my 20’s.
22. Have you ever had CT scans? I do not remember if I had one when they took out my
appendix, that was a long time back.
23. Have you ever been hospitalized? I had my appendix taken out when I was 20. I spent a
couple days in the hospital.
24. Have you had any significant traumatic injuries or accidents? No.
25. What childhood illnesses have you had? The usual coughs, colds, and tummy aches.
Nothing remarkable.
26. Do you have a history of a bowel obstruction? No.
27. Do you have any allergies? No
28. Are you taking any prescription medications? Just the HCTZ 25mg QD. I think it works
and controls my blood pressure OK.
29. Are you taking any OTC or herbal medications? Aleve for back pain.
30. Do you have trouble taking medicines the way you have been told to take them? No
31. Are you taking any medications for your symptoms? No
32. Have you been taking your medications as prescribed? Yes
33. When was your last physical? Don’t remember
34. Are your immunizations up to date? I had a flu shot this year, but I’m not sure it works.
35. Have you had your diptheria, tetanus, and acellular pertussis vaccine? – Do you really
need to know that?
36. What cancer screening tests have you had, and what were the results? I haven’t had any
tests.
37. When and what were the results of your last prostate exam? Not that long ago. It was
normal.
38. Have you recently traveled? Where did you go? No
39. Tell me about the health of your grandparents, parents, and children. – My daughter is
fine. My parents have their issues I guess. I am not aware of my grandparents’ health.
40. Are there any diseases that run in your family? I don’t know. My father drank too much
too and had a gastric ulcer. He died a while ago from a heart attack. My brother is 51 and
doesn’t have any problems. My mom has HTN, she had basal cell carcinoma which was
excised but is fine now.
41. Anything new in your family medical history I should know about? No
42. Do you know of any genetic diseases that are found in your family? No
43. Does anyone in your family have anemia? No
44. Do you have a family history of sudden death? Yeah, my dad.
45. Have either of your parents or a blood sibling died? From what? And how old were they?
My father died from a heart attack when he was 61. My mom and brother are still alive.
46. Tell me about your work. --- I’m an engineer at a large software company
47. Have you had more pressure at work? No
48. Do you drink alcohol? If so, what do you drink and how many drinks per day? Yeah. 3-4
beers and some whiskey each day. Sometimes more.
49. Has drinking alcohol ever caused you problems? Yeah. I know I should cut back. I black
out every couple of weeks and can’t remember anything. I once tried to quit cold turkey,
and my co-worker had to bring me to the hospital because I was trembling and out of it.
50. Do you ever have withdrawal symptoms if you don’t drink for a day or two? Feeling
shaky or jittery? That happened to me the one time I tried to quit cold turkey. A coworker
had to take me to the hospital.
51. Have you recently been intoxicated? Yeah, pretty much every day.
52. Have you ever felt you needed to cut down on your drinking? Yes. I know I should.
53. Any diet changes since your last appointment? – What? Why are you asking this?
54. Do you have any problem swallowing? No
55. Do you use any recreational drugs? If so, what? Not anymore. I used marijuana in the
past. But that was at least 10 years ago now.
56. Have you/do you use cocaine? No
57. Do you use IV drugs? No
58. Do you now/have you ever smoked/chewed tobacco? Yeah, both. I did for about 10 years,
but quit around 7 years ago.
59. Tell me about your diet, what you normally eat. ---Seems fine to me.
60. How much water/fluids do you drink in a day? A normal amount
61. Do you drink caffeinate beverages or eat chocolate? No
62. Tell me about your social/leisure activities. -- I don’t have much to tell.
63. Tell me about your daily exercise/sports that you play. – I don’t play sports
64. On average, how many hours per night do you sleep? 6-8 hours.
65. Do you have a family? Yeah.
66. Do you have any children? Spouse? Significant partner? I have a grown daughter. I’m
divorced and live alone now.
67. Do you use a cane, crutches or walker? No
68. Do you have medical insurance? Yes
69. Do you have an advance directive? I’m not sure.
70. Can you afford the co-pays for your clinic visits and medications? Yeah.
71. Within your list of responsibilities and priorities, where does your health fall? ---Why do
you need to know that?
72. What community resources do you have access to that can provide assistance? I don’t
know why you are asking me this.
73. Are you sexually active? No
74. Have you had any STD? No
75. When and what did you last eat? Don’t totally remember. I’m not keeping anything down
anyway.
76. Do you have any fatigue, difficulty sleeping, unintentional weight loss/gain, fevers or
night sweats? I can’t imagine trying to sleep right now with all this throwing up. No
fever. I have been dragging a bit lately, before all this started. Do you think I caught a
really bad bug?
77. Do you have itchy scalp, skin changes, moles, thinning hair or brittle nails? None of any
of that.
78. Do you have any headaches that won’t go away with aspirin or Tylenol, double/blurred
vision, difficulty with night vision, problems, hearing, ear pain, sinus problems, chronic
sore throats, or difficulty swallowing? No
79. Have you noticed any breast discharge, lumps, scaly nipples, pain , swelling or redness?
No
80. Do you experience chest pain discomfort/pressure, pain/pressure/dizziness with exertion
or getting angry, palpitations, decreased exercise tolerance, or blue/cold fingers/toes? No
81. Do you experience SOB, wheezing, difficulty catching your breath, chronic cough, or
sputum production? I do huff and puff when I climb a lot stairs, but I think it is dues to
my lack of exercise.
82. Do you have nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark
tarry stool, bright red blood in your bowel movements, early satiety, or bloating? Yes a
bunch of that s
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