Gastrointestinal | Transcript .pdf - Gastrointestinal | Completed | Shadow Health Gastrointestinal Results | Turned In Advanced Health Assessment

Gastrointestinal | Transcript .pdf - Gastrointestinal |...

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Unformatted text preview: 5/29/2018 Gastrointestinal | Completed | Shadow Health Gastrointestinal Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: May 29, 2018 | Patient Exam Time: 198 min All Lines (227) Interview Questions (152) Statements (17) Exam Actions (58) Objective Data Collection Education & Empathy Hello my name is Sara an FNP student and will be interviewing you today Documentation Lifespan Greet 05/29/18 10:20 AM CDT Hey. Review Questions Self-Reflection will you state your name (Clarified to what is your name.) Question 05/29/18 10:20 AM CDT Tina Jones. what is your date of birth Question 05/29/18 10:24 AM CDT February 17th. how old are you ? Question 05/29/18 10:26 AM CDT I'm 28. what brought you in to the clinic today? Question 05/29/18 10:35 AM CDT I've been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me. 1/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Sorry you are feeling so bad Empathize 05/29/18 10:38 AM CDT Thanks for understanding. when do you notice the pain? (Clarified to when does the pain start.) Question 05/29/18 10:41 AM CDT It starts pretty quickly after I finish eating. Like within ten or fifteen minutes. when did the pain start? Question 05/29/18 10:42 AM CDT Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad. Where is the pain located? Question 05/29/18 10:43 AM CDT It's like... my upper stomach. Like right below my breastbone, in the middle. describe how the pain feels? Question 05/29/18 10:44 AM CDT Um, it feels like heartburn. But sometimes, if it's bad, it's sharper than that. Does the pain increase? Question 05/29/18 11:00 AM CDT Yeah, it's getting worse over time. I get these stomach pains every day. Is there an increase in pain? (Clarified to Did the pain change?.) Question 05/29/18 11:00 AM CDT Yeah, it's getting worse over time. I get these stomach pains every day. How many times a week are you getting this PAIN 2/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 11:01 AM CDT Every time I eat it hurts a little, but 3 or 4 times a week, it'll be a lot worse. do you have this pain every day? (Clarified to Do you have abdominal pain every day.) Question 05/29/18 11:03 AM CDT Yeah, it's getting worse over time. I get these stomach pains every day. when does your abdominal pain begin (Clarified to When did the abdominal discomfort begin?.) Question 05/29/18 11:04 AM CDT Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad. When does the pain begin? Question 05/29/18 11:07 AM CDT It starts pretty quickly after I finish eating. Like within ten or fifteen minutes. How long does the pain last? Question 05/29/18 11:07 AM CDT For a few hours after I eat. Will you rate your pain on a Pain Scale 0 out of 10 Question 05/29/18 11:08 AM CDT Right now, it's like a 1 or 2. But after I eat, it's like a. . . 5? Rate your pain when lying down? Question 05/29/18 11:09 AM CDT If I've eaten and try to lie down, that's when it's the worst. Like a 6 or 7. Is the pain crushing? Question 05/29/18 11:09 AM CDT 3/28 5/29/2018 Gastrointestinal | Completed | Shadow Health No. Is the pain gnawing? Question 05/29/18 11:10 AM CDT No, it's not like that. Is the pain cramping? Question 05/29/18 11:10 AM CDT No, it's not like stomach cramps. Does your abdomen tender to touch? Question 05/29/18 11:10 AM CDT No. My stomach pain's not tender like that. Where is your pain located Question 05/29/18 11:55 AM CDT It's like... my upper stomach. Like right below my breastbone, in the middle. Does your pain radiate? Question 05/29/18 11:55 AM CDT No, it's right in the center of my stomach, like between my belly button and my ribs. Does your pain radiate? Question 05/29/18 11:58 AM CDT No, it's right in the center of my stomach, like between my belly button and my ribs. Shoulder pain? Question 05/29/18 11:59 AM CDT No. 4/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Any back pain? Question 05/29/18 11:59 AM CDT My back feels fine. Arm pain? (Clarified to do you have pain in your arm.) Question 05/29/18 11:59 AM CDT No, it's right in the center of my stomach, like between my belly button and my ribs. Any flank pain? Question 05/29/18 11:59 AM CDT No -- my pain is like, on my front. In the middle of my stomach. What side of your stomach? Question 05/29/18 12:00 PM CDT I feel pain after I eat, multiple times throughout the day. It kinda feels like burning, like heartburn. What side is your pain on (No matching questions found.) Question 05/29/18 12:00 PM CDT On what side do you feel the pain? (No matching questions found.) Question 05/29/18 12:00 PM CDT Is the pain on your right side? (Clarified to Do you have sharp pain in your right lower abdomen?.) Question 05/29/18 12:00 PM CDT No, it's not at all like that. It's in the middle of my stomach. I'm sorry you're feeling so bad Empathize 05/29/18 12:03 PM CDT Thanks for saying that. Your pain occurs after eating? 5/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 12:04 PM CDT Yes. Every time I eat it hurts. I've been eating less because I don't like being in pain. Your pain is with larger meals? Question 05/29/18 12:04 PM CDT If I eat too much, or if I have something spicy. But I quit eating spicy food already. Do fatty foods make it worse? (Clarified to do you eat a lot of fatty food.) Question 05/29/18 12:04 PM CDT Not too much. I mean, I like French fries and stuff, but I try not to eat them too often. French fries are considered a fatty food. Let's try to cut down on those french fries Educate 05/29/18 12:05 PM CDT Alright, thanks for letting me know. Is the pain worse when you bend over? Question 05/29/18 12:05 PM CDT Yeah. It gets worse when I bend over -- I noticed that at work. Sorry to hear that Empathize 05/29/18 12:05 PM CDT I appreciate you saying that. Does it hurt when you lie flat Question 05/29/18 12:06 PM CDT Yeah. Try to refrain from bending over at work Educate 05/29/18 12:07 PM CDT 6/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Thanks for telling me. Is your pain decreased between meals? Question 05/29/18 12:07 PM CDT No, it's gotten worse and worse over time. How do you feel between meals? Question 05/29/18 12:07 PM CDT Yeah, I usually have a couple of snacks during the day. Is your pain better when you sit up? Question 05/29/18 12:09 PM CDT Usually, yeah. Any decrease in appetite? Question 05/29/18 12:09 PM CDT Yeah, I haven't been wanting to eat lately. It is important that you still eat 3 times a day Educate 05/29/18 12:10 PM CDT That makes sense. You eat out? Question 05/29/18 12:10 PM CDT I try not to eat out too much, but with my schedule I end up having to. Are you eating smaller meals? (Clarified to Have you been eating smaller meals than usual.) Question 05/29/18 12:11 PM CDT Yeah, I've been trying to eat really little meals. I haven't been that hungry, and I don't want to have the pain of eating a big meal. 7/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Are you eating spicy foods? Question 05/29/18 12:11 PM CDT Well, I used to eat spicy food sometimes, but in the last few weeks I can't. It makes my stomach pain too bad. Any increase in burping? Question 05/29/18 12:13 PM CDT Yeah, that's been happening after I eat. Any recent weight loss? Question 05/29/18 12:13 PM CDT No, I don't think so. Tested skin turgor on forearm Exam Action 05/29/18 12:24 PM CDT Inspected right side of abdomen Exam Action 05/29/18 12:25 PM CDT Inspected front of abdomen Exam Action 05/29/18 12:25 PM CDT Inspected left side of abdomen Exam Action 05/29/18 12:25 PM CDT Inspected front of abdomen Exam Action 05/29/18 12:25 PM CDT Auscultated breath sounds in anterior right upper lobe Exam Action 05/29/18 12:28 PM CDT Auscultated breath sounds in anterior left upper lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 05/29/18 12:29 PM CDT 8/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Auscultated breath sounds in anterior right middle lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in anterior left lower lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in anterior right lower lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior left upper lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior right upper lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior left lower lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior right lower lobe Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior right lower lobe on side Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior right lower lobe near spine Exam Action 05/29/18 12:29 PM CDT Auscultated breath sounds in posterior left lower lobe near spine Exam Action 05/29/18 12:30 PM CDT Auscultated breath sounds in posterior left lower lobe on side Exam Action 05/29/18 12:30 PM CDT 9/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Auscultated aortic area with the bell Exam Action 05/29/18 12:31 PM CDT Auscultated aortic area with the diaphragm Exam Action 05/29/18 12:31 PM CDT Auscultated pulmonic area with the diaphragm Exam Action 05/29/18 12:31 PM CDT Auscultated Erb's point with the diaphragm Exam Action 05/29/18 12:31 PM CDT Auscultated tricuspid area with the diaphragm Exam Action 05/29/18 12:31 PM CDT Auscultated tricuspid area with the bell Exam Action 05/29/18 12:31 PM CDT Auscultated mitral area with the bell Exam Action 05/29/18 12:31 PM CDT Auscultated right upper quadrant Exam Action 05/29/18 12:32 PM CDT Auscultated left upper quadrant Exam Action 05/29/18 12:34 PM CDT Auscultated left lower quadrant Exam Action 05/29/18 12:34 PM CDT Auscultated right lower quadrant Exam Action 05/29/18 12:34 PM CDT Auscultated aorta in abdomen Exam Action 05/29/18 12:35 PM CDT Auscultated left renal artery Exam Action 05/29/18 12:36 PM CDT 10/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Auscultated right renal artery Exam Action 05/29/18 12:36 PM CDT Auscultated left iliac artery Exam Action 05/29/18 12:36 PM CDT Auscultated right iliac artery Exam Action 05/29/18 12:36 PM CDT Auscultated left femoral artery Exam Action 05/29/18 12:37 PM CDT Auscultated right femoral artery Exam Action 05/29/18 12:37 PM CDT Percussed left lower quadrant Exam Action 05/29/18 12:39 PM CDT Percussed left upper quadrant Exam Action 05/29/18 12:39 PM CDT Percussed right lower quadrant Exam Action 05/29/18 12:39 PM CDT Percussed right upper quadrant Exam Action 05/29/18 12:39 PM CDT Percussed right flank for CVA tenderness Exam Action 05/29/18 12:40 PM CDT Percussed left flank for CVA tenderness Exam Action 05/29/18 12:40 PM CDT Percussed spleen Exam Action 05/29/18 12:41 PM CDT Percussed for liver span: 7 cm in the mid-clavicular line Exam Action 05/29/18 12:42 PM CDT 11/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/29/18 12:44 PM CDT Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/29/18 12:44 PM CDT Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/29/18 12:44 PM CDT Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/29/18 12:45 PM CDT Palpated right upper quadrant with deep pressure: No masses Exam Action 05/29/18 12:46 PM CDT Palpated right lower quadrant: with deep pressure: No masses Exam Action 05/29/18 12:46 PM CDT Palpated left upper quadrant with deep pressure: No masses Exam Action 05/29/18 12:46 PM CDT Palpated left lower quadrant with deep pressure: No masses Exam Action 05/29/18 12:46 PM CDT Palpated liver: Palpable 1 cm below right costal margin Exam Action 05/29/18 12:48 PM CDT Palpated for spleen: Not palpable Exam Action 05/29/18 12:49 PM CDT Palpated for left kidney: Not palpable Exam Action 05/29/18 12:49 PM CDT Any new medications to report? Question 05/29/18 12:52 PM CDT No, just my inhalers. I guess I've been taking antacid chews sometimes for my stomach, too. How about frequent Advil use? (No matching questions found.) 12/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 12:52 PM CDT How often do you use ibuprofen? (Clarified to how frequently do you take Advil.) Question 05/29/18 12:52 PM CDT I only take it when I get cramps from my period, and I take kind of a lot for the first three days. I probably take it three times a day, and I take three at a time. What is the name of antacid you take Question 05/29/18 12:53 PM CDT I take the chewable Tums. How often are you taking Tums? Question 05/29/18 12:54 PM CDT I take them every few days. Just if the heartburn gets bad. How many times a day do you take the antacid? Question 05/29/18 12:54 PM CDT I don't take them every day. How many times do you chew a time? (No matching questions found.) Question 05/29/18 12:54 PM CDT How many times do you chew tums Question 05/29/18 12:55 PM CDT I brush my teeth at least twice a day--every morning and at night. How many times tums do you take at a time Question 05/29/18 12:55 PM CDT I start with two, and then I chew a couple more if I need to. The bottle says you can have up to four. Do the Tums help with your pain? 13/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 12:55 PM CDT I feel the best in-between meals. And sitting up on the couch seems to help. And sometimes I take an antacid. It is important to follow the instructions on the bottle. Educate 05/29/18 12:56 PM CDT Sure, I think I understand what you mean. How many times do you take at one time Question 05/29/18 12:56 PM CDT I start with two, and then I chew a couple more if I need to. The bottle says you can have up to four. Do the antacids relieve your pain (Clarified to Does taking the antacids help.) Question 05/29/18 12:57 PM CDT Yeah, they help. I try to only take them when the pain seems worse than usual. When did you last take Tums? Question 05/29/18 12:57 PM CDT Yesterday, after dinner. Any new allergies to report? Question 05/29/18 12:58 PM CDT No, not that I know of. Can you confirm your allergies? (No matching questions found.) Question 05/29/18 12:58 PM CDT What are you allergic to? Question 05/29/18 12:58 PM CDT I'm allergic to cats. 14/28 5/29/2018 Gastrointestinal | Completed | Shadow Health What happens when you around cats? (Clarified to what happens when you are around a cat.) Question 05/29/18 12:59 PM CDT Whenever I'm around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. Are you allergic to dust? Question 05/29/18 12:59 PM CDT Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. Are you allergic to penicillin? Question 05/29/18 1:00 PM CDT Yes. What happens if you take penicillin? Question 05/29/18 1:00 PM CDT I don't remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. You take any other medications? (Clarified to what other medications are you taking.) Question 05/29/18 1:02 PM CDT Just the Flovent inhaler. . . and the Proventil that I had before, but I haven't needed that in a while. What is the dose of the flovent Question 05/29/18 1:02 PM CDT I start with two, and then I chew a couple more if I need to. The bottle says you can have up to four. How much flovent do you use? Question 05/29/18 1:03 PM CDT Not very much. What is your dose of flovent? 15/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 1:03 PM CDT I start with two, and then I chew a couple more if I need to. The bottle says you can have up to four. Where did you last use your flovent? Question 05/29/18 1:04 PM CDT This morning, I had breakfast at home. Any history of gastrointestinal disease? (Clarified to Have you had gastrointestinal disease?.) Question 05/29/18 1:06 PM CDT I don't have like, diseases. But I've had this stomach pain for like, a month. History of GERD? Question 05/29/18 1:07 PM CDT No. Gastrointestinal surgery? Question 05/29/18 1:07 PM CDT No. History of appendicitis? Question 05/29/18 1:07 PM CDT No. History of cholecystitis? Question 05/29/18 1:07 PM CDT Not that I've heard of. History of stomach cancer? Question 05/29/18 1:07 PM CDT 16/28 5/29/2018 Gastrointestinal | Completed | Shadow Health No. History of liver disease? (Clarified to do you have liver disease.) Question 05/29/18 1:08 PM CDT No, I've never had any problems with my liver. Do you have kidney disease? Question 05/29/18 1:08 PM CDT No. As far as I know, I've never had anything wrong with my kidneys. Do you have history of bladder disease? Question 05/29/18 1:08 PM CDT Not that I've heard of. Do you have a history of ulcers? Question 05/29/18 1:08 PM CDT No. How often do you have a bowel movement? Question 05/29/18 1:09 PM CDT Usually every other day. Do you have pain during your bowel movements? Question 05/29/18 1:09 PM CDT No. Any blood in your bowel movements? Question 05/29/18 1:10 PM CDT Um, no. 17/28 5/29/2018 Gastrointestinal | Completed | Shadow Health Any Tarry stools? Question 05/29/18 1:10 PM CDT Um, no. Any mucus in your stool? Question 05/29/18 1:10 PM CDT Ew. No. Can you describe the consistency of your bowel movements? Question 05/29/18 1:10 PM CDT It's normal, I think. Not hard, and not too, uh, soft or anything. Increase in urination? Question 05/29/18 1:12 PM CDT Yeah, but I've been drinking more water. What color is your urine? Question 05/29/18 1:12 PM CDT Um, light yellow or almost clear? The regular color. Any pain with urination? Question 05/29/18 1:12 PM CDT No. Do you have to get up in the middle of the night to urinate? Question 05/29/18 1:12 PM CDT Yeah, I definitely get up more than once during the night. Any blood in your urine? Question 05/29/18 1:13 PM CDT 18/28 5/29/2018 Gastrointestinal | Completed | Shadow Health I don't think so... My pee hasn't been red or anything. Any incontinence? (Clarified to have you had accidents in the bathroom.) Question 05/29/18 1:13 PM CDT No, I haven't had problems with that. When was your last menstrual period? Question 05/29/18 1:14 PM CDT I think it was just about a month ago. Are you sexually active? Question 05/29/18 1:14 PM CDT Um, not right now. what did you have for breakfast? Question 05/29/18 1:42 PM CDT This morning, I had toast with butter and honey, and some orange juice. What does your lunch consist of? (Clarified to what do you usually eat for lunch.) Question 05/29/18 1:43 PM CDT I usually either make a sandwich and bring it with me, or I get a sandwich somewhere. And I have chips or pretzels with it. Or *maybe* French fries, but I try not to get them too often. What did you eat yesterday for breakfast? Question 05/29/18 1:44 PM CDT I had a small bowl of cereal. What did you have yesterday for lunch? Question 05/29/18 1:44 PM CDT I had a piece of pizza. It was someone's birthday at work, so they ordered pizza for all of us. 19/28 5/29/2018 Gastrointestinal | Completed | Shadow Health The pizza may be contributing to your stomach pain Educate 05/29/18 1:45 PM CDT OK, I understand. What did you have for dinner yesterday? Question 05/29/18 1:45 PM CDT Last night we...
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