Gastrointestinal | Completed | Shadow Health 1.pdf - Gastrointestinal Results | Turned In Advanced Health Assessment Spring 2019 NSG516 Online Return to

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Unformatted text preview: Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Assignment Your Results Overview Reopen Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 49 out of 52 Objective Data Collection Education & Empathy Documentation Self-Reflection Student Survey Proficiency Level: Proficient Beginning Digital Clinical Experience Score 99.3% This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 84.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent. Developing Proficient Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner. Subjective Data Collection Objective Data Collection 17 out of 18 30 out of 30 Education and Empathy 2 out of 4 Time 67 minutes total spent in assignment Interaction with patient Post-exam activities 59 minutes 8 minutes Transcript Started: Mar 09, 2019 | Patient Exam Time: 59 min All Lines (145) Interview Questions (73) Statements (13) Exam Actions (59) Hi Tina, I am Juliana, the nurse practitioner student. I will interview and examine you today. Nice seeing you again. Greet 03/09/19 9:51 AM EST Hey. What brings you in? Question 03/09/19 9:51 AM EST I've been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me. Sorry to hear you are having trouble with stomach pain. Let;s see if we can figure out what the problem is. Empathize 03/09/19 9:52 AM EST Thanks for saying that. When did the stomach pain start? Question 03/09/19 9:52 AM EST Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad. Can you describe the stomach pain? Question 03/09/19 9:52 AM EST Um, it feels like heartburn. But sometimes, if it's bad, it's sharper than that. Does anything make the pain worse? Question 03/09/19 9:52 AM EST Eating seems to cause it. Oh, what a burden! Hopefully you are not experiencing it all the time! Empathize 03/09/19 9:53 AM EST I appreciate you telling me that. Do greasy foods make the pain worse? Question 03/09/19 9:53 AM EST I don't think so. What makes the pain worse? Question 03/09/19 9:53 AM EST Eating seems to cause it. What makes the stomach pain better? Question 03/09/19 9:53 AM EST I feel the best in-between meals. And sitting up on the couch seems to help. And sometimes I take an antacid. How often do you take antacids? Question 03/09/19 9:54 AM EST I take them every few days. Just if the heartburn gets bad. How much do antacids help? Question 03/09/19 9:54 AM EST Yeah, they help. I try to only take them when the pain seems worse than usual. I am glad to hear you are able to get some relief from the antacids Empathize 03/09/19 9:54 AM EST Thanks. Does the stomach pain radiate? Question 03/09/19 9:55 AM EST No, it's right in the center of my stomach, like between my belly button and my ribs. How often do you get stomach pain? It started really gradually, so I didn't notice for awhile that it was happening more and more often. Now it's like, every day. Question 03/09/19 9:55 AM EST It must be hard to have to deal with stomach pains daily. Empathize 03/09/19 9:55 AM EST I appreciate you saying that. How long does the pain last? Question 03/09/19 9:55 AM EST For a few hours after I eat. How would you rate the stomach pain from 0-10? Question 03/09/19 9:56 AM EST Right now, it's like a 1 or 2. But after I eat, it's like a. . . 5? How long does the stomach pain last? Question 03/09/19 9:56 AM EST For a few hours after I eat. A daily pain of 5/10 is a lot to deal with. Empathize 03/09/19 9:56 AM EST Thanks for understanding. Does the pain interfere with your life? (Clarified to Has the pain affected your usual activities?.) Question 03/09/19 9:57 AM EST Not too much. I'm still able to do everything with work and school. But it affects the way I eat -- I haven't wanted to eat much, because I feel like it's gonna hurt if I eat the wrong thing, or if I eat too much at one time. (Clarified to if my pain has affected my activities.) Question 03/09/19 9:59 AM EST What foods make it worse? Definitely spicy food. I stopped eating anything spicy. And any really big meal makes it hurt worse. How does the stomach pain affect your appetite? Question 03/09/19 9:59 AM EST Yes. Every time I eat it hurts. I've been eating less because I don't like being in pain. I am surprised you havent lost more weight. Lets come up with a plan to address it Empathize 03/09/19 10:00 AM EST Thanks for saying that. Has the stomach pain caused weight loss? Question 03/09/19 10:00 AM EST 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. I completely understand. Empathize 03/09/19 10:01 AM EST Thanks for understanding. Eating smaller meals and making some diet modifications can help with these symptoms. Educate 03/09/19 10:01 AM EST That makes sense. Have you lost weight? Question 03/09/19 10:01 AM EST No, I don't think so. Have you been burping lately? Yeah, that's been happening after I eat. Question 03/09/19 10:02 AM EST DO you have any allergies? Question 03/09/19 10:02 AM EST Yeah, I'm allergic to cats. What is your reaction to cat allergies? Question 03/09/19 10:02 AM EST Whenever I'm around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. Do you have medication allergies? Question 03/09/19 10:02 AM EST Yeah, I'm allergic to penicillin. What is your reaction to penicillin? Question 03/09/19 10:02 AM EST 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. Do you have any trouble breathing? Question 03/09/19 10:02 AM EST Well, I have asthma, but I haven't had much trouble with it. With my inhaler, it's under control. What medications do you currently take? Question 03/09/19 10:03 AM EST I have a daily inhaler. And I've been taking antacid chews sometimes for my stomach, too. Do you take any other over the counter medications? No, the only thing lately has been those antacid chews. How often do you use the antacid chews Question 03/09/19 10:03 AM EST Question 03/09/19 10:03 AM EST I take them every few days. Just if the heartburn gets bad. Do you drink alcohol? Question 03/09/19 10:04 AM EST Not lately, but I do every so often. How much alcohol do you drink per month? Question 03/09/19 10:04 AM EST I only go out 2 or 3 times a month at the most. I haven't been out in a couple weeks. How many drinks do you have per month? Question 03/09/19 10:04 AM EST We're talking, like... maybe twice a month, I meet up with friends and have 2 to 3 drinks. That's like, 6 a month. And I haven't had a drink in at least 2 weeks. DO you smoke? Question 03/09/19 10:05 AM EST No, I've never smoked a cigarette in my life. Good for you! Empathize 03/09/19 10:05 AM EST Thanks. Do you use recreational drugs? Yeah, in high school and a little after that I smoked pot sometimes. But I haven't done anything like that in a long time. Question 03/09/19 10:05 AM EST Do you have a history of gastrointestinal problems? Question 03/09/19 10:05 AM EST I don't have a history of gastrointestinal problems. I've never experienced this before. [AUDIO COMING SOON] Are you constipated? Question 03/09/19 10:06 AM EST I don't have that problem. Do you have regular bowel movements? Question 03/09/19 10:06 AM EST Um, I don't go every day... I probably go every two days. That's normal for me. Do you have regular urination? Question 03/09/19 10:06 AM EST Well. . . I would say I've been peeing a lot more lately. When did you start peeing a lot more? Question 03/09/19 10:06 AM EST I guess it started. . . maybe a few months? But I've been drinking a lot more water, too. Have you been more thirsty? Question 03/09/19 10:07 AM EST You know, I did notice lately that I've been really thirsty. When did you last have a bowel movement? I haven't gone yet today, but I did last night. Question 03/09/19 10:07 AM EST Do you have loose stools? Question 03/09/19 10:07 AM EST No. Do you have blood in the stools? Question 03/09/19 10:08 AM EST Um, no. Have you had diarrhea? Question 03/09/19 10:08 AM EST No. Have you had a lot of gas? (Clarified to Do you feel gassy?.) Question 03/09/19 10:08 AM EST No. (Clarified to if I am gassy.) Do you feel nauseous? Question 03/09/19 10:08 AM EST No, I'm fine. Do you feel dizzy? Question 03/09/19 10:08 AM EST No, I'm not dizzy but I feel pretty crappy. I am sorry to hear you feel this way! Empathize 03/09/19 10:09 AM EST I appreciate you saying that. Do you have regular periods? Question 03/09/19 10:09 AM EST It's not regular. Sometimes it's every month, but sometimes it's more like every two months. I don't write it down or anything. I probably get...six periods a year. Are you sexually active? Question 03/09/19 10:09 AM EST Um, not right now. When was your last meal? Question 03/09/19 10:09 AM EST This morning, I had breakfast at home. What did you eat for breakfast? Question 03/09/19 10:09 AM EST This morning, I had toast with butter and honey, and some orange juice. Did your breakfast cause pain? (No matching questions found.) Question 03/09/19 10:10 AM EST What did you eat in the last 24 hours? Question 03/09/19 10:10 AM EST Um ...Yesterday, I had ... Let me start at breakfast. I had a bowl of cereal. For lunch ... I had a piece of pizza. For dinner, I made baked potatoes with broccoli and cheese soup. This morning I had toast with butter and honey, and some orange juice, and that's the last thing I've had. What is your typical diet like? Question 03/09/19 10:10 AM EST It's pretty good, I think. I'm not a huge health nut or anything. What do you usually eat for breakfast? Question 03/09/19 10:11 AM EST I usually have either cereal or toast, or if I pick something up on my way to work, I'll get a muffin or some pumpkin bread. What do you usually eat for lunch? Question 03/09/19 10:11 AM EST 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 do you usually eat for dinner? Question 03/09/19 10:11 AM EST Oh, we try to make something easy. We eat a lot of frozen chicken breasts. We do hamburgers that we make at home every so often. We make sure we have a vegetable, and we eat a lot of potatoes. And we usually have rolls or something. What do you usually eat for snacks? Question 03/09/19 10:11 AM EST Well, if I'm at home, I would have pretzels or chips. Or crackers, whatever we had around. If I'm on my way to work or campus... sometimes I stop and get a small thing of French fries at Sonic. What do you like to drink? Question 03/09/19 10:11 AM EST Most of the time I just drink Diet Cokes. Do you drink water? Question 03/09/19 10:11 AM EST Yeah, I've been drinking tons of water lately. Do you drink coffee? No, I never drink it. Do you exercise? Question 03/09/19 10:12 AM EST Question 03/09/19 10:12 AM EST I don't have the energy to go to a gym or anything after work. . . I'm pretty exhausted by the end of the day. But I'm on my feet all the time at work so I feel like that's a little bit of exercise most days at least. Have your dietary patterns changed? Question 03/09/19 10:12 AM EST 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. Sometimes, sitting up after meals and avoiding to eat about 2-3 hours prior to going to bed can be very helpful with these symptoms. Educate 03/09/19 10:13 AM EST Sure, I think I understand what you mean. Did any stressful life events happened? Question 03/09/19 10:14 AM EST Not that I can think of. I've been really busy with work and school. That's been stressful. Are you feeling depressed? Question 03/09/19 10:14 AM EST The closest I ever came to depression was after Dad died. . . I just felt sad all the time. I am sure you did. Its normal do feel sad when we lose a loved one Empathize 03/09/19 10:15 AM EST I appreciate you telling me that. Are you feeling sad or blue? No, I'm pretty even-keel. I mean, I have good days and bad days like everybody, but nothing crazy. Question 03/09/19 10:15 AM EST Are you feeling anxious? Question 03/09/19 10:15 AM EST Not too much -- I can get a little anxious and stressed because I'm busy and I work hard. I might have some anxiety lately. Especially since I'd like to get this heartburn fixed. With some lifestyle modifications you will be able to get the heartburn fixed. Educate 03/09/19 10:16 AM EST Alright, thanks for letting me know. Do you eat out a lot? Question 03/09/19 10:16 AM EST I try not to eat out too much, but with my schedule I end up having to. Have you changed anything about your diet? Question 03/09/19 10:16 AM EST No, I'm a creature of habit. I eat the same foods all the time. Do you have a family history of GI disorders? Question 03/09/19 10:17 AM EST No, my family doesn't have any gastrointestinal issues. Well, Grandpa Jones died from colon cancer, if that counts. Any recent major stressful life events? Question 03/09/19 10:17 AM EST Not that I can think of. I've been really busy with work and school. That's been stressful. Do you have dietary restrictions? I avoid sugar because of my diabetes, but otherwise I can eat whatever I want. Question 03/09/19 10:17 AM EST Do you have a fever? Question 03/09/19 10:18 AM EST No. No fever. May I examine you? Question 03/09/19 10:18 AM EST Sure. Tested skin turgor on forearm Exam Action 03/09/19 10:18 AM EST Inspected right side of abdomen Exam Action 03/09/19 10:18 AM EST Inspected front of abdomen Exam Action 03/09/19 10:18 AM EST Inspected left side of abdomen Exam Action 03/09/19 10:18 AM EST Inspected front of abdomen Exam Action 03/09/19 10:18 AM EST Auscultated breath sounds in anterior right upper lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in anterior left upper lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in anterior right middle lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in anterior right lower lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in anterior left lower lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior left upper lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior right upper lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior left lower lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior right lower lobe Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior right lower lobe on side Exam Action 03/09/19 10:19 AM EST Auscultated breath sounds in posterior left lower lobe on side Exam Action 03/09/19 10:20 AM EST Auscultated breath sounds in posterior left lower lobe near spine Exam Action 03/09/19 10:20 AM EST Auscultated breath sounds in posterior right lower lobe near spine Exam Action 03/09/19 10:20 AM EST Auscultated aortic area with the bell Exam Action 03/09/19 10:20 AM EST Auscultated aortic area with the diaphragm Exam Action 03/09/19 10:20 AM EST Auscultated pulmonic area with the diaphragm Exam Action 03/09/19 10:20 AM EST Auscultated Erb's point with the diaphragm Exam Action 03/09/19 10:20 AM EST Auscultated tricuspid area with the diaphragm Exam Action 03/09/19 10:20 AM EST Auscultated mitral area with the diaphragm Exam Action 03/09/19 10:20 AM EST Auscultated right upper quadrant Exam Action 03/09/19 10:21 AM EST Auscultated right lower quadrant Exam Action 03/09/19 10:21 AM EST Auscultated right upper quadrant Exam Action 03/09/19 10:21 AM EST Auscultated left upper quadrant Exam Action 03/09/19 10:21 AM EST Auscultated left lower quadrant Exam Action 03/09/19 10:21 AM EST Auscultated aorta in abdomen Exam Action 03/09/19 10:21 AM EST Auscultated right renal artery Auscultated left renal artery Exam Action 03/09/19 10:21 AM EST Exam Action 03/09/19 10:21 AM EST Auscultated right iliac artery Exam Action 03/09/19 10:21 AM EST Auscultated left iliac artery Exam Action 03/09/19 10:21 AM EST Auscultated right femoral artery Exam Action 03/09/19 10:21 AM EST Auscultated left femoral artery Exam Action 03/09/19 10:22 AM EST Percussed right lower quadrant Exam Action 03/09/19 10:22 AM EST Percussed right upper quadrant Exam Action 03/09/19 10:22 AM EST Percussed left upper quadrant Exam Action 03/09/19 10:22 AM EST Percussed left lower quadrant Exam Action 03/09/19 10:22 AM EST Percussed right flank for CVA tenderness Exam Action 03/09/19 10:22 AM EST Percussed left flank for CVA tenderness Exam Action 03/09/19 10:22 AM EST Percussed spleen Percussed for liver span: 7 cm in the mid-clavicular line Exam Action 03/09/19 10:22 AM EST Exam Action 03/09/19 10:23 AM EST Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Comments Exam Action 03/09/19 10:23 AM EST Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/09/19 10:23 AM EST Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/09/19 10:23 AM EST Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 03/09/19 10:23 AM EST Palpated right lower quadrant: with deep pressure: No masses Exam Action 03/09/19 10:24 AM EST Palpated right upper quadrant with deep pressure: No masses Exam Action 03/09/19 10:24 AM EST Palpated left upper quadrant with deep pressure: No masses Exam Action 03/09/19 10:24 AM EST Palpated left lower quadrant with deep pressure: No masses Exam Action 03/09/19 10:24 AM EST Palpated liver: Palpable 1 cm below right costal margin Exam Action 03/09/19 10:24 AM EST Palpated for spleen: Not palpable Exam Action 03/09/19 10:24 AM EST Palpated for right kidney: Not palpable Exam Action 03/09/19 10:24 AM EST Palpated for left kidney: Not palpable Exam Action 03/09/19 10:25 AM EST If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018 ...
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