Gastrointestinal | Completed | Shadow Health 2.pdf - Gastrointestinal Results | Turned In Advanced Health Assessment Spring 2019 NSG516 Online Return to

Gastrointestinal | Completed | Shadow Health 2.pdf -...

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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 30 out of 30 Objective Data Collection 17 out of 18 Education and Empathy 2 out of 4 Time 67 minutes total spent in assignment Interaction with patient Post-exam activities 59 minutes 8 minutes Subjective Data Collection: 30 of 30 (100.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Category Scored Items Indicates an item that you found. Indicates an item that is available to be found. Patient Data Not Scored Experts selected these topics as essential components of a strong, thorough interview with this patient. A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports frequently occurring stomach pain History of Present Illness Asked about onset of pain Reports noticing pain for "at least a month" Reports that pain increased gradually Asked about frequency of pain Reports pain occurs every day Reports 3 to 4 episodes a week that are more severe Asked about duration of pain Pain begins right after finishing a meal Each episode lasts "a few hours" Asked about severity of pain on a scale Rates present pain as 1 or 2 out of 10 Rates worst pain after eating as 5 out of 10 Rates pain when supine as a 6 or 7 out of 10 Asked about character of the pain Describes the pain as similar to heartburn Denies crushing pain Denies gnawing pain Denies cramping pain Denies that abdomen is tender to the touch Asked location of the pain Pain is in center of upper stomach, below breastbone Pain does not radiate Denies shoulder pain Denies back pain Denies arm pain Denies flank pain Denies pain on right side of abdomen Asked about aggravating factors Pain occurs after eating Pain worsens with larger meals Reports that spicy foods increase the pain Denies high-fat foods as an aggravating factor Pain worsens when supine Pain worsens when bending over Asked about relieving factors Pain improves between meals Pain improves when upright Asked about effects of pain on diet and appetite Reports decreased appetite Describes not wanting to eat out of anticipation of pain Reports eating smaller meals Reports avoiding spicy foods Asked about increased burping Reports burping Burping occurs after eating Asked about changes in weight Denies recent weight loss Medical History Confirmed use of medications Confirms medications (no new medications reported) Reports occasional antacid use Denies frequent Advil (ibuprofen) use Followed up on use of antacids and relieving factors Antacid brand is Tums Takes antacids every few days Takes between 2 and 4 antacid tablets at a time Reports that antacids offer partial relief Confirmed allergies Asked about past gastrointestinal history Confirms allergies (no new allergies reported) Denies gastrointestinal disease Denies past history of GERD Denies past gastrointestinal surgery Denies past history of appendicitis Denies past history of cholecystitis Denies past history of stomach cancer Denies past history of liver disease Denies past history of kidney disease Denies past history of bladder disease Denies past history of ulcers Asked about typical bowel movements Reports bowel movement every 2 days Denies pain during bowel movements Denies bloody or tarry stools Denies mucus in stool Describes consistency of bowel movements Asked about typical urination Reports increased urination Reports urine is a clear or light-yellow color Reports nocturia Denies pain during urination Describes urine character as normal Denies pink or bloody urine Denies incontinence Asked about menstruation and sexual activity LMP was 3 weeks ago Denies sexual activity Social History Asked about most recent meal Most recent meal was breakfast this morning Most recent meal was toast with butter and honey and orange juice Asked 24-hour diet recall Yesterday's breakfast was cereal Yesterday's lunch was pizza Yesterday's dinner was a baked potato Asked about typical diet Reports typical intake is 3 meals a day plus snacks Typical breakfast is cereal, bread, or a muffin Typical lunch is a sandwich and chips Typical dinner is chicken, a vegetable or potatoes, and bread Reports fast food intake 3 times a week Typical snack is pretzels, French fries, crackers or chips Asked about typical beverages Last alcoholic drink was 2 weeks ago Typical alcohol frequency is 2 - 3 times a month Typical alcohol intake is 2 - 3 drinks at a time Reports that alcohol intake bothered her stomach Reports drinking soda Reports drinking 3 - 4 diet cokes a day Reports that she hasn't noticed a connection between soda intake and pain Reports drinking 6 - 8 glasses of water a day Asked about recent dietary and life experiences Asked about substance use Denies recent travel Denies food poisoning Denies illicit drug use Denies cigarette smoking Review of Systems Asked about general symptoms Denies fever Denies chills Denies fatigue Denies night sweats Asked about review of systems for mental health Reports occasional feelings of anxiety Asked about review of systems for gastrointestinal Denies nausea Reports feelings of stress Denies vomiting Denies diarrhea Denies constipation Denies flatus Denies bloating Asked about review of systems for respiratory Denies sore throat Denies coughing Denies dysphagia Denies difficulty breathing Denies chest pain Denies palpitations Denies change in sense of taste Family History Asked about relevant family history Reports family history of colon cancer Denies family history of GERD Denies family history of IBS Denies family history of cholecystitis Denies family history of liver disease Denies family history of kidney disease Denies family history of bladder disease Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018 ...
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