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Peptic ulcers are dangerous. As one expert said, Your own blood will kill you. A bleeding ulcer can kill you if left unattended for a long time. The pain of an ulcer is felt anywhere in the area between the navel and the upper breast bone. But with the onset of the bleeding, the ulcer will become painless as the blood neutralizes the acid that is eroding on your raw flesh. Because it is mostly painless, it is difficult for most people to realize that something is wrong. Some will actually think their ulcer just got better. One out of every ten people with a bleeding ulcer has reported it to have been painless; this can get very deadly very fast (Cooper, 2010).

Peptic ulcer disease is associated with major morbidity. Each year peptic ulcer disease affects 4 million people around the world. Complications are encountered in 10%-20% of these patients and 2%-14% of the ulcers will perforate. Perforated peptic ulcer is quite rare, but life threatening disease and the mortality varies from 10%-40%. Females account for more than half the cases; they are older and have more comorbidity than their male counterparts. According to the latest WHO data published in April 2011 Peptic Ulcer Disease deaths in the Philippines reached 7,423 or 1.76% of total deaths. The age adjusted death rate is 14.83 per 100,000 of population ranks Philippines #2 in the world (Chua, 2012).

Peptic ulcer disease is one of the most common diseases affecting the GI tract. An ulcer is an area of the stomach lining that is literally being eaten away by your stomach acid. When a peptic ulcer affects the stomach it is called a gastric ulcer, one in the duodenum is called a duodenal ulcer, while an esophageal ulcer is an ulcer in the esophagus (Marks, 2012).

The most important symptoms that these ulcers cause are related to bleeding. Bleeding from an ulcer can be slow and go unnoticed or can cause life threatening hemorrhage. Ulcers that bleed slowly might not produce the symptoms until the person becomes anemic. Symptoms of anemia include fatigue, shortness of breath with exercise and pale skin color. Bleeding that occurs more rapidly might show up as melena or even large amount of dark red or maroon blood in the stool. People with bleeding ulcers may also vomit. This vomit may be red blood or may look like coffee grounds. Other symptoms might include passing out or feeling lightheaded. Symptoms of rapid bleeding represent a medical emergency (Marks, 2012).

Therefore, a timely diagnosis plays a crucial role in the treatment of stomach ulcers. The sooner the stomach ulcer symptoms are recognized, the better it is. If the symptoms are diagnosed early, this condition can be cured within a short span of time. On the contrary, turning a blind eye to the early symptoms can worsen the situation, and cause a lot of pain and discomfort to the individual (Cooper, 2010).

For that, the theory of Unpleasant Symptoms is an effective guide that can be used to understand the different symptoms that the individual is experiencing. An understanding of a nursing theory can help the healthcare providers to conceptualize nursing care in the context of a comprehensive framework. Symptoms not only create distress but also disrupt social functioning. A symptom is a subjective experience reflecting changes in the bio psychosocial functioning, sensations or cognition of an individual. Patients with peptic ulcer disease may experience a range of symptoms from mild abdominal pain and burning to bleeding, vomiting or catastrophic perforation of the organ lining, a life threatening condition requiring emergency surgery (Lenz, 2013).

Because the symptom experience, by definition, occurs at the level of individual perception, the theory is applicable at the level of the individual. However, the TOUS does not consider the individual in isolation. Rather, it positions the individual within the context of his or her family, social and organizational networks and community by taking into account situational factors in the environment that may influence the symptom experience. It embodies an inclusive perspective that is not limited to the physical domain of human experience of symptoms, but also acknowledges the important influence of psychological factors and situational or environmental factors, as well as their interplay on the experience of symptoms. It also defines the outcome of the symptom experience in terms of performance, a notion that considers its impact on the individuals interactions with others and his or her short and long term physical, cognitive, and social functioning (Lenz, 2013).

Being able to personally experience having poor health, feeling incapable of major activity, restricted on bed and unable to work because of abdominal pain are some of the reasons why the researcher chose this study. The researcher also selected this because of the flourishing number of people being affected with peptic ulcer disease and how this case made a young patient in her teens struggle with various symptoms and threatens her life. The researcher chose this theory because of its emphasis on symptom management. The theory helps improve understanding of symptom experience in various contexts and to provide information useful for designing effective interventions to prevent, ameliorate or manage unpleasant symptoms and their negative effects. Hopefully, the study will help in advancing patients knowledge by being able to describe characteristics of their symptom experience and its consequences in their daily life.


The Theory of Unpleasant Symptoms (TOUS) was originally developed by Lenz, Pugh, Milligan, Gift, and Suppe in 1995. In order to make the model of unpleasant symptoms less linear and reflect the dynamics of clinical situations, the authors revised the TOUS in 1999. The theory focuses on the symptom experience, with multiple symptoms occurring together, rather than one symptom in isolation. TOUS is based on the assumption that sufficient commonalities exist among symptoms. The theory uniquely implies that the management of one symptom will contribute to the management of other symptoms. TOUS therefore addresses the synchronic occurrence of more than one symptom that may exert a multiplicative effect on symptom experience, distress, and performance (Lenz, 2013).

The relationships among the components of the TOUS are interconnected with one another. The symptoms that the individual is experiencing; the influencing factors that give rise to or affect the nature of the symptom experience; and the consequences of the symptom experiences. Physiological, psychological, and situational factors are antecedent factors which influence the symptom experience. The consequence of symptoms is performance which includes functional and cognitive activities (Lenz, 2013).

Symptoms are the central focus of the TOUS. Symptoms are defined as perceived indicators of change in normal functioning as experienced by patients. Symptoms can be considered alone or combination. They are seen as multiplicative, rather than additive. In the original model of the TOUS, one symptom is depicted and it is a purely linear model. The updated model of the TOUS proposes that symptoms can occur alone or in isolation from one another but that, more often, multiple symptoms are experienced simultaneously. The revised model also reflects more interaction among key components (Lenz, 2013).

Multiple symptoms can occur together as a result of a single event. Each symptom is conceptualized to be a multidimensional experience, which can be conceptualized and measured separately or in combination with other symptoms. Symptoms have the dimensions of intensity (severity), timing (frequency, duration, and relationship to events), distress (the persons reaction to the sensation), and quality (descriptors used to characterize the symptom, location of the symptom, or response to intervention). Intensity refers to the severity, strength, or amount of the symptom being experienced (Smith, 2013).

It is proposed that three categories of influential factors, physiological, psychological, and environmental/situational affect ones predisposition to or manifestation of a given unpleasant symptom experience. The influencing factors are also the antecedents of the symptom experience in the TOUS. Physiological factors are often reflected in unpleasant symptoms associated with alterations in the normal functioning of bodily systems or the existence of any pathology. Physiological antecedents commonly characterize the severity of the disease, such as comorbidities, abnormal laboratory findings or other pathological findings (Smith, 2013).

The psychological factors that are antecedents include the individuals mental state or mood (depression), affective reaction to illness (mood status), psychological response to stress (the degree of perceived stress or the level of anxiety) and degree of uncertainty and knowledge about the symptoms and their possible meaning (perception of illness experience or symptom experience). Situational/environmental antecedents include aspects of the social and physical environment that may affect the individuals experience and reporting of symptoms (Smith, 2013).

In the original model of the TOUS, influential factors are depicted exerting a unidirectional influence on the symptom experience, and not related to one another. In the updated model of the TOUS, some improvements have been made to more accurately depict these relationships. First, the three types of influential factors are related to one another over and above their individual relationships to symptoms. Second, the model asserts that physiological, psychological, and situational factors can interact with one another in their relation to symptoms (Brant, 2010)

Outcome or consequence of the symptom experience is the final component of the theory of unpleasant symptoms. Performance is conceptualized to include functional status or performance, cognitive functioning, and physical performance. Functional performance is conceptualized broadly to include physical activity, activities of daily living (ADLs), social activities and interaction, and role performance including work and other role-related tasks. Cognitive performance includes concentrating, thinking, and problem-solving. Performance is affected by the level and nature of the symptom experience (Brant, 2010).

Compared to the original TOUS model, the revised TOUS model more accurately depicts the relationships among symptom experiences, influential factors and outcomes. First, the revised TOUS model depicts reciprocal relationships among central concepts (influential/antecedent factors, symptom experience, and outcomes/ consequences). Second, the experience of unpleasant symptoms can change ones physiological, psychological, and situational status. Third, the revised TOUS model proposes that outcomes (performance) have a reciprocal relation with the symptom experience. The revised model also posits that decreased levels of performance can have a negative feedback loop to the influential factors (physiological, psychological, and situational factors). Additionally, antecedents/ influential factors can have an interaction effect in their relation to the symptom experience. Furthermore, the symptom experience can have a moderating or mediating influence on the relationship between influential factors and outcomes (Smith, 2013).




Influences with

Influencing Factors

Unpleasant Symptoms


Physiological Factors

Co- morbidities

Pathological Findings

Situational Factors



Psychological factors

Mood Status

Level of Stress

Memorial Symptom Assessment Scale (MSAS)

14 Unpleasant Symptoms Identified

(Shortness of Breath; Nausea and Vomiting; Dry Mouth; Cough; Worrying; Feeling Drowsy; Dizziness; Lack of Energy; Difficulty Swallowing; Swelling of Legs; Lack of Appetite; Pain; Constipation; Itching)

Evaluation: Performance Outcome




Symptom Management

Care Plan

Nursing Interventions

Interacts with



Researcher Made Assessment Tool

Using Lenzs Theory of Unpleasant Symptoms, a conceptual model of symptom and symptom management was developed. The conceptual framework for this study comprised of three key components: influential factors, symptom experience and outcomes. Symptoms as conceptualized in the theory manifest multiple variables and dimensions; these are being assessed in terms of their intensity, distress, time and quality as per the study using the Memorial Symptom Assessment Scale. There were 14 unpleasant symptoms identified in the study. Unpleasant experiences or symptoms are directly affected by influential factors such as physiological, psychological and situational factors which were also assessed in the study using the Researcher- Made Assessment Tool. Symptoms also have a mediating effect between influential factors and symptom management. So, as the data were gathered, a nursing care plan was formulated which guided the researcher in the implementation of the nursing interventions all throughout the 50 hours intensive practicum. The interventions made were specifically designed to prevent, ameliorate or manage the unpleasant symptoms identified. The effectiveness of the symptom management rendered was then evaluated by means of the performance outcomes which comprises of the physical, cognitive and social functionality of the patient. Symptom management is the outcome of unpleasant experiences; therefore unpleasant symptoms directly influence symptom management.


This study aimed to utilize the Theory of Unpleasant Symptoms in the care of a patient with bleeding peptic ulcer disease.

It answers the following sub problems:

1. What are the different influencing factors of the patient causing unpleasant symptoms in terms of the following factors:

1. a. physiological;

1. b. psychological;

1. c. situational?

2. What is the psychopathophysiological process of Bleeding Peptic Ulcer Disease?

3. What are the unpleasant symptoms identified by the researcher in terms of:

3. a. intensity;

3. b. distress;

3. c. time;

3. d. quality?

4. What nursing interventions are implemented to manage these unpleasant symptoms?

5. What were the performance outcomes of the patient in terms of:

5. a. physical functioning;

5. b. cognitive functioning;

5. c. social functioning?


The result of this study can serve as a guide in managing multiple symptoms experienced by the patients. They are the recipients of nursing care and considered as the beneficiaries of all nursing interventions to be implemented by the health care providers in which appropriate therapy is given to promote faster recovery.

The patients significant others can also benefit from this study because it teaches them about symptom identification and strategies that would manage unpleasant symptoms on which they can apply in home care settings.

Moreover, this will also be helpful for the individual nurses as for them to be aware on symptom identification and symptom management. This utilizes a symptomatic approach in the care of a patient which is commonly seen in the hospital setting. This equips them knowledge in providing care to patients in a symptomatic approach.

Additionally the nurse practitioners can take middle range theories and develop practice guidelines based on them. This helps them yield valuable information about patients' symptom experiences. Theory guided practice elevates the work of nurses leading to fulfillment and satisfaction and providing a satisfying professional model of practice.

As for the nursing academe, the blossoming of middle range theories signifies a growth of knowledge development in nursing because the growth of the nursing discipline is dependent on the systematic and continuing application of nursing knowledge in practice and development of new knowledge.

This study will also assist the student nurses to understand and be more aware on the symptom characteristics. This helps the students realize that symptoms may be interrelated with one another which can cause a greater stress to their patients. With the help of symptom identification and the characteristics of each symptom in terms of intensity, distress, time and quality, the student nurses can come up with care plans that alleviate not only the symptom itself but also the etiology.

Furthermore, this study will also improve the nurse researchers understanding of the theory as it was applied in an actual setting and care of a patient. This makes the researcher understand how the influencing factors can affect the symptoms and in turn affect the performance outcome of the patient.


Research Design

The study made use of a qualitative case study research design that provides an empirical inquiry that investigates a phenomenon within its real-life context by one or more methods. Case studies focus intently on the collection and presentation of detailed information on individuals or small groups to draw conclusions about the individuals or groups in a specific context. The goal of case studies is not to find a definitive cause-effect relationship, but rather to describe and explore the behavior to reach a better understanding of the research question (Thomas, 2010).

Research Locale

The study was conducted in Vicente Sotto Memorial Medical Center (VSMMC) which is located at B. Rodriguez avenue Cebu City. In general, VSMMC is a tertiary medical center as well as a teaching/ training medical facility owned by the Philippine Government. It aims to provide health care services that are available, affordable, accessible and acceptable to all regardless of social status. The hospital has 800 bed capacities and accommodates various cases such as Internal Medicine, Pediatrics, Surgery, Orthopedics, Obstetrics, Gynecology, Ophthalmology, ENT (Ears, Nose and Throat), Psychiatry and Communicable Diseases. The hospital also offers Emergency Room Services, Out-Patient Services, Clinical Specialty Services, Operating Room Services, Organ Transplant Unit, Critical Care Unit Services, Cardiac Catheterization Services, Hemodialysis Unit, Peritoneal Dialysis Unit, Laboratory and Diagnostic Services. The Medical Ward (Ward IX) where the study was conducted had a 77 bed capacity.

Research Instrument

The study made use of a researcher made assessment tool coupled by the Memorial Symptom Assessment Scale (MSAS) developed by Russell Portenoy to aid in gathering data. It is a patient rated instrument that was developed to provide multidimensional information about a diverse group of common symptoms. The MSAS is a reliable and valid instrument for the assessment of symptom prevalence, characteristics and distress. It provides a method for a comprehensive symptom assessment that may be useful when information about symptoms is desirable.

Data Gathering Procedure

The researcher made a letter of request which was approved by the dean of the college of nursing, the VPAA and the school president. The letter was then submitted to the chief nurse of VSMMC where the study was conducted. Subsequently, the researcher engaged in a 50 hours intensive practicum at VSMMC. Patient selection highly depended on the type and severity of the case presentation. Prior to any data gathering procedure, the researcher introduced herself to the client and explained the purpose of her visits to establish rapport and gain cooperation. Once a nurse- client relationship was established assessment followed. Throughout the course of patient care, demographic variables (gender, age, education, employment and marital status) were taken. Clinical characteristics such as etiology of the illness, diagnosis, co-morbidities, medical management done and prescribed medications given were collected from the medical record. Assessment and gathering of data such as patient history and evaluation of symptoms was aided by the researcher made tool and the Memorial Symptom Assessment Scale.


Results and Discussion


A.R. is an 18 year old, female, single, Filipino, Roman Catholic, a second year college student from Dalaguete Cebu. She was admitted for the second time at Vicente Sotto Memorial Medical Center under the services of Dr. M. Suarez for complaints of hematemesis and epigastric pain noted an hour PTA.


A. Physiological Factor

Two days prior to admission, the patient had been experiencing intermittent cramping pain at the epigastric area aggravated by eating. It was described to be non-radiating and was associated with shortness of breath, feeling of weakness, tarry stool and hematemesis. Self-medicated with Aluminum Hydroxide +Magnesium Hydroxide+ Simethicone tablet, 1tab 3x a day which provided no relief. This condition hindered her from doing her daily activities. Due to financial difficulty, patient endured the illness that she was experiencing until the time that she could no longer bear the pain. Because pain was becoming more intense, patient was brought to VSMMC by her sister to seek for medical advice. Upon arrival at the emergency room patient vomited blood, now approximating to be about 500 to 1000 ml of coffee ground vomitus. It was decided upon based on the consideration of the symptoms that the patient manifested and on the physical examination that the patient was to be admitted and to be closely monitored.

For the patients past medical history, patient claimed that she experienced common childhood diseases and minor illnesses, such as common cold, chicken pox, mumps and measles. However, patient also mentioned that in year 2006 she was admitted at VSMMC for the same complaint of epigastric pain and hematemesis, she was discharged improved after 4 days with a diagnosis of peptic ulcer disease. Patient is non- asthmatic, non-diabetic, non-hypertensive, non-smoker and a non-alcoholic beverage drinker. She does not recall of having any history of allergies. Every time the patient has a health problem, she would usually self-medicate with over the counter drugs such as Paracetamol 500mg/tab taken every 4 hours for fever and Aluminum Hydroxide +Magnesium Hydroxide+ Simethicone tablet taken three times a day for her abdominal pain. And if the symptoms persist then she seeks medical assistance at the barangay health center in their municipality.

Before hospitalization, the patient normally ate her meal before hospitalization at 6am-12pm-7pm. Patient claimed that due to school work and activities, she would rather skip meals and finish her work. She didnt take any vitamin supplements. The patient took 6 to 8 glasses of water daily. She usually consumes a cup of rice and a half serving of viand every meal usually having vegetables or fish.

During hospitalization, the patient was placed on an NPO status and was advised by the doctor to have a clear liquid diet after 4 days NPO and a soft diet meal after 2 days of clear liquid diet. The patient regularly ate her meal at 7am-11am-6pm. She was served with a cup of rice porridge. She was given ferrous sulfate and multivitamins to supplement her dietary intake. The patient took 6 to 8 glasses of water daily.

The patient had normal bladder elimination before hospitalization. She voided three to four times a day. The amount of her daily voiding was approximately three to four glasses of urine with yellow clear color. According to the patient, she experienced no pain every time she urinated. During hospitalization, there was no change with regards to her bladder elimination pattern.

Before hospitalization, the patient had regular bowel elimination twice daily. The color of her stool was tarry black with a normal consistency as a manifestation of GI bleeding. During hospitalization, she had one episode of bowel elimination after her fourth day stay in the hospital after she was given a rectal suppository. The color of her stool was still tarry black with normal consistency.

As for the patients sleeping pattern, she usually sleeps only six hours every night before hospitalization and didnt take nap during the day. During hospitalization, her sleeping pattern increased from six hours to eight hours but sometimes be awaken due to heat and discomforts in the environment. She was still experiencing pain at sometimes but it was relieved due to the medication given to her.

B. Psychological Factor

The patient could understand and express her feelings well. She is a second year college student and a school scholar. The patient could interpret her physical condition with regards to her illness and doesnt have difficulty expressing herself to her family and others. Patient could recall important events of her life. The patient informed that in making major decisions, the whole family discussed and together decides. Patient did not have difficulty in decision making regarding her confinement.

The patient describes herself as a happy person. Her family gives her strength. Her family feels saddened with her illness but they learned to accept it. She is satisfied with her physical appearance and feels saddened with other people who had disabilities and illness. She considers her present condition as the most stressful situation in her life because it affects them financially and emotionally. Her family supports her to cope up with her present condition. The patient is not so religious, but she often prays to God for guidance and blessings. Her family serves as her motivation in life.The most important for her is to have a good life together with her family and be able to provide for their needs.

C. Situational Factor

Both of her parents are farmers in their hometown. The patient is the fourth among the six siblings of which four are females and two are males. Currently, the patient lives with her aunt in the city along with her two sisters. Except for herself, she claimed that her family members are healthy. As stated by the patient, she perceived herself a not so healthy individual for she was admitted twice and currently suffering from PUD. Right now her normal activities are affected due to her present illness.

Before hospitalization, the patient usually starts her day at 5am to prepare for school. She attends class at 7am and finishes at 6pm. She also helps her aunt in doing household chores when she gets home and after which she studies her lessons and do her home works. But due to increasing pain which happens intermittently during the day, the patient was restricted of doing her normal daily activities. During hospitalization, patient was confined in the hospital for recovery thus her daily activities were altered.

As a college scholar, she claimed that her major responsibility is to do well in school and to have good grades. She is eager to finish school so that she could provide financial support to her family. She considers her family as the most important aspect of her life. She claimed that their neighborhood is peaceful and a good community and they lived there a long time already.


The stomach is located in the upper part of the abdomen just beneath the diaphragm. The stomach is distensible and on a free mesentery, therefore, the size, shape, and position may vary with posture and content. An empty stomach is roughly the size of an open hand and when distended with food, can fill much of the upper abdomen and may descend into the lower abdomen or pelvis on standing. The stomach may be divided into seven major sections: the cardia that is distal to the esophagogastric junction; the fundus that refers to the superior portion of the stomach; the antrum which is the smaller distal one-fourth of the stomach; the narrow pylorus that connects the stomach and duodenum; the lesser curve refers to the medial shorter border of the stomach, whereas the opposite surface is the greater curve; the angularis which is along the lesser curve of the stomach where the body and antrum meet, and is accentuated during peristalsis (Hopkins, 2010).

The duodenum extends from the pylorus to the ligament of Treitz in a sharp curve that almost completes a circle. It is so named because it is about equal in length to the breadth of 12 fingers, or about 25 cm. It is largely retroperitoneal and its position is relatively fixed. It is divided into four portions: the superior portion which begins at the pylorus, and passes beneath the liver to the neck of the gallbladder; the descending part takes a sharp curve and goes down along the right margin of the head of the pancreas; the duodenum turns medially, becoming the horizontal portion, and passes across the spinal column; the ascending portion begins at the left of the spinal column, where the intestine angles forward and downward to become the jejunum. The stomach and duodenum are closely related in function, and in the pathogenesis and manifestation of disease (Hopkins, 2010).

Peptic ulcers are defects in the gastric or duodenal mucosa that extend through the muscularis mucosa. The epithelial cells of the stomach and duodenum secrete mucus in response to irritation of the epithelial lining and as a result of cholinergic stimulation. The superficial portion of the gastric and duodenal mucosa exists in the form of a gel layer, which is impermeable to acid and pepsin. Other gastric and duodenal cells secrete bicarbonate, which aids in buffering acid that lies near the mucosa. Prostaglandins of the E type (PGE) have an important protective role, because PGE increases the production of both bicarbonate and the mucous layer (Anand, 2012).

In the event of acid and pepsin entering the epithelial cells, additional mechanisms are in place to reduce injury. Within the epithelial cells, ion pumps in the basolateral cell membrane help to regulate intracellular pH by removing excess hydrogen ions. Through the process of restitution, healthy cells migrate to the site of injury. Mucosal blood flow removes acid that diffuses through the injured mucosa and provides bicarbonate to the surface epithelial cells (Longstreth, 2011).

Under normal conditions, a physiologic balance exists between gastric acid secretion and gastroduodenal mucosal defense. Mucosal injury and, thus, peptic ulcer occur when the balance between the aggressive factors and the defensive mechanisms is disrupted. Aggressive factors, such as NSAIDs, H. pylori infection, alcohol, bile salts, acid, and pepsin, can alter the mucosal defense by allowing back diffusion of hydrogen ions and subsequent epithelial cell injury. The defensive mechanisms include tight intercellular junctions, mucus, mucosal blood flow, cellular restitution, and epithelial renewal (Taylor, 2013).

The gram-negative spirochete H. pylori is a major part of the triad, which includes acid and pepsin, that contributes to primary peptic ulcer disease. The unique microbiologic characteristic of this organism, such as urease production, allows it to alkalinize its microenvironment and survive for years in the hostile acidic environment of the stomach, where it causes mucosal inflammation (Anand, 2012).

Once the ulcer has developed, this causes inflammatory response in order to aid in tissue repair. Inflammatory mediators cause pain in the area. Consistent irritation by medications or irritating foods can aggravate the condition and lead to perforation or hemorrhage. The presence of perforation may lead to peritonitis and may become life-threatening because of sepsis and profuse bleeding (Taylor, 2013).


In the Memorial Symptom Assessment Scale (MSAS), there are 32 common symptoms being identified. The scale measures the intensity, distress and frequency level of each symptom. The symptoms identified in the MSAS are either physical symptoms and or psychological symptoms. Among the 32 listed symptoms, only 14 symptoms were experienced by the patient.

Symptom 1. Shortness of Breath

Patient rated this symptom as very severe and claimed to be very much distressed with the experience of this symptom. It was almost constantly present during the entire course of her hospitalization.

Symptom 2. Nausea and Vomiting

Patient rated this symptom as very severe and claimed to be very much distressed with the experience of this symptom. It was almost constantly present during the entire course of her hospitalization.

Symptom 3. Dry Mouth

Patient rated this symptom as very severe and claimed to be very much distressed with the experience of this symptom. It was almost constantly present during the entire course of her hospitalization.

Symptom 4. Cough

Patient rated this symptom as severe and claimed to be very much distressed with the experience of this symptom. It was almost constantly present during the entire course of her hospitalization.

Symptom 5. Worrying

Patient rated this symptom as very severe and claimed to be very much distressed with the experience of this symptom. It was frequently present during the entire course of her hospitalization.

Symptom 6. Feeling Drowsy

Patient rated this symptom as very severe and claimed to be very much distressed with the experience of this symptom. It was occasionally present during the entire course of her hospitalization.

Symptom 7. Dizziness

Patient rated this symptom as moderately severe and claimed to be somewhat distressed with the experience of this symptom. It was almost constantly present during the entire course of her hospitalization.

Symptom 8. Lack of Energy

Patient rated this symptom as moderately severe and claimed to be quite a bit distressed. This symptom was frequently present during the entire course of her hospitalization.

Symptom 9. Difficulty Swallowing

Patient rated this symptom as moderately severe and claimed to be quite a bit distressed with the experience of this symptom. It was frequently present during the course of her hospitalization.

Symptom 10. Swelling of Legs

Patient rated this symptom as severe and claimed to be somewhat distressed with the experience of this symptom. It was occasionally present during the course of her hospitalization.

Symptom 11. Lack of Appetite

Patient rated this symptom as moderately severe and claimed to be somewhat distressed with the experience of this symptom. It was frequently present during the course of her hospitalization.

Symptom 12. Pain

Patient rated this symptom as moderately severe and claimed to be somewhat distressed with the experience of this symptom. It was occasionally present during the course of her hospitalization.

Symptom 13. Constipation

Patient rated this symptom as moderately severe and claimed to be a little bit distressed with the experience of this symptom. It was frequently present during the entire course of her hospitalization.

Symptom 14. Itching

Patient rated this symptom as moderately severe and claimed to be quite a bit distressed with the experience of this symptom. It was rarely present during the course of her hospitalization.