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Gastrointestinal Transcript

Tina jones shadow health assessment for gastrointestinal transcript do...
Course

Diagnostic assessment (MSN610)

31 Documents
Students shared 31 documents in this course
Academic year: 2021/2022
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This document has been uploaded by a student, just like you, who decided to remain anonymous.
Northern Kentucky University

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Gastrointestinal Results | Turned In

Advanced Health Assessment - Chamberlain, NR509-April-

Return to Assignment

Your Results Lab Pass Lab Pass

Started: May 29, 2018 | Patient Exam Time: 198 min

Transcript

Greet 05/29/18 10:20 AM CDT

Question 05/29/18 10:20 AM CDT

Question 05/29/18 10:24 AM CDT

Question 05/29/18 10:26 AM CDT

Question 05/29/18 10:35 AM CDT

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Lifespan

Review Questions

Self-Reflection

Interview Questions (152)Interview Questions (152) Statements (17)Statements (17) Exam Actions (58)Exam Actions (58)

Hello my name is Sara an FNP student and will be interviewing youHello my name is Sara an FNP student and will be interviewing you

todaytoday

Hey.

will you state your name (Clarified to what is your name.)will you state your name (Clarified to what is your name.)

Tina Jones.

what is your date of birthwhat is your date of birth

February 17th.

how old are you ?how old are you?

I'm 28.

what brought you in to the clinic today?what brought you in to the clinic today?

I've been having this stomach pain for awhile. It keeps coming back,

and it really is starting to bother me.

All Lines (227)All Lines (227)

Empathize 05/29/18 10:38 AM CDT

Question 05/29/18 10:41 AM CDT

Question 05/29/18 10:42 AM CDT

Question 05/29/18 10:43 AM CDT

Question 05/29/18 10:44 AM CDT

Question 05/29/18 11:00 AM CDT

Question 05/29/18 11:00 AM CDT

Sorry you are feeling so badSorry you are feeling so bad

Thanks for understanding.

when do you notice the pain? (Clarified to when does the pain start.)when do you notice the pain? (Clarified to when does the pain start.)

It starts pretty quickly after I finish eating. Like within ten or fifteen

minutes.

when did the pain start?when did the pain start?

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?Where is the pain located?

It's like... my upper stomach. Like right below my breastbone, in the

middle.

describe how the pain feels?describe how the pain feels?

Um, it feels like heartburn. But sometimes, if it's bad, it's sharper

than that.

Does the pain increase?Does the pain increase?

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?.)Is there an increase in pain? (Clarified to Did the pain change?.)

Yeah, it's getting worse over time. I get these stomach pains every

day.

How many times a week are you getting this PAINHow many times a week are you getting this PAIN

Question 05/29/18 11:10 AM CDT

Question 05/29/18 11:10 AM CDT

Question 05/29/18 11:10 AM CDT

Question 05/29/18 11:55 AM CDT

Question 05/29/18 11:55 AM CDT

Question 05/29/18 11:58 AM CDT

Question 05/29/18 11:59 AM CDT

No.

Is the pain gnawing?Is the pain gnawing?

No, it's not like that.

Is the pain cramping?Is the pain cramping?

No, it's not like stomach cramps.

Does your abdomen tender to touch?Does your abdomen tender to touch?

No. My stomach pain's not tender like that.

Where is your pain locatedWhere is your pain located

It's like... my upper stomach. Like right below my breastbone, in the

middle.

Does your pain radiate?Does your pain radiate?

No, it's right in the center of my stomach, like between my belly

button and my ribs.

Does your pain radiate?Does your pain radiate?

No, it's right in the center of my stomach, like between my belly

button and my ribs.

Shoulder pain?Shoulder pain?

No.

Question 05/29/18 11:59 AM CDT

Question 05/29/18 11:59 AM CDT

Question 05/29/18 11:59 AM CDT

Question 05/29/18 12:00 PM CDT

Question 05/29/18 12:00 PM CDT

Question 05/29/18 12:00 PM CDT

Question 05/29/18 12:00 PM CDT

Empathize 05/29/18 12:03 PM CDT

Any back pain?Any back pain?

My back feels fine.

Arm pain? (Clarified to do you have pain in your arm.)Arm pain? (Clarified to do you have pain in your arm.)

No, it's right in the center of my stomach, like between my belly

button and my ribs.

Any flank pain?Any flank pain?

No -- my pain is like, on my front. In the middle of my stomach.

What side of your stomach?What side of your stomach?

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.)What side is your pain on (No matching questions found.)

On what side do you feel the pain? (No matching questions found.)On what side do you feel the pain? (No matching questions found.)

Is the pain on your right side? (Clarified to Do you have sharp pain inIs the pain on your right side? (Clarified to Do you have sharp pain in

your right lower abdomen?.)your right lower abdomen?.)

No, it's not at all like that. It's in the middle of my stomach.

I'm sorry you're feeling so badI'm sorry you're feeling so bad

Thanks for saying that.

Your pain occurs after eating?Your pain occurs after eating?

Question 05/29/18 12:07 PM CDT

Question 05/29/18 12:07 PM CDT

Question 05/29/18 12:09 PM CDT

Question 05/29/18 12:09 PM CDT

Educate 05/29/18 12:10 PM CDT

Question 05/29/18 12:10 PM CDT

Question 05/29/18 12:11 PM CDT

Thanks for telling me.

Is your pain decreased between meals?Is your pain decreased between meals?

No, it's gotten worse and worse over time.

How do you feel between meals?How do you feel between meals?

Yeah, I usually have a couple of snacks during the day.

Is your pain better when you sit up?Is your pain better when you sit up?

Usually, yeah.

Any decrease in appetite?Any decrease in appetite?

Yeah, I haven't been wanting to eat lately.

It is important that you still eat 3 times a dayIt is important that you still eat 3 times a day

That makes sense.

You eat out?You eat out?

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 eatingAre you eating smaller meals? (Clarified to Have you been eating

smaller meals than usual.)smaller meals than usual.)

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.

Question 05/29/18 12:11 PM CDT

Question 05/29/18 12:13 PM CDT

Question 05/29/18 12:13 PM CDT

Exam Action 05/29/18 12:24 PM CDT

Exam Action 05/29/18 12:25 PM CDT

Exam Action 05/29/18 12:25 PM CDT

Exam Action 05/29/18 12:25 PM CDT

Exam Action 05/29/18 12:25 PM CDT

Exam Action 05/29/18 12:28 PM CDT

Exam Action 05/29/18 12:29 PM CDT

Exam Action 05/29/18 12:29 PM CDT

Are you eating spicy foods?Are you eating spicy foods?

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?Any increase in burping?

Yeah, that's been happening after I eat.

Any recent weight loss?Any recent weight loss?

No, I don't think so.

Tested skin turgor on forearm Tested skin turgor on forearm

Inspected right side of abdomen Inspected right side of abdomen

Inspected front of abdomen Inspected front of abdomen

Inspected left side of abdomen Inspected left side of abdomen

Inspected front of abdomen Inspected front of abdomen

Auscultated breath sounds in anterior right upper lobe Auscultated breath sounds in anterior right upper lobe

Auscultated breath sounds in anterior left upper lobe Auscultated breath sounds in anterior left upper lobe

Auscultated breath sounds in anterior left mid-chest (upper lobe) Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:31 PM CDT

Exam Action 05/29/18 12:32 PM CDT

Exam Action 05/29/18 12:34 PM CDT

Exam Action 05/29/18 12:34 PM CDT

Exam Action 05/29/18 12:34 PM CDT

Exam Action 05/29/18 12:35 PM CDT

Exam Action 05/29/18 12:36 PM CDT

Auscultated aortic area with the bell Auscultated aortic area with the bell

Auscultated aortic area with the diaphragm Auscultated aortic area with the diaphragm

Auscultated pulmonic area with the diaphragm Auscultated pulmonic area with the diaphragm

Auscultated Erb's point with the diaphragm Auscultated Erb's point with the diaphragm

Auscultated tricuspid area with the diaphragm Auscultated tricuspid area with the diaphragm

Auscultated tricuspid area with the bell Auscultated tricuspid area with the bell

Auscultated mitral area with the bell Auscultated mitral area with the bell

Auscultated right upper quadrant Auscultated right upper quadrant

Auscultated left upper quadrant Auscultated left upper quadrant

Auscultated left lower quadrant Auscultated left lower quadrant

Auscultated right lower quadrant Auscultated right lower quadrant

Auscultated aorta in abdomen Auscultated aorta in abdomen

Auscultated left renal artery Auscultated left renal artery

Exam Action 05/29/18 12:36 PM CDT

Exam Action 05/29/18 12:36 PM CDT

Exam Action 05/29/18 12:36 PM CDT

Exam Action 05/29/18 12:37 PM CDT

Exam Action 05/29/18 12:37 PM CDT

Exam Action 05/29/18 12:39 PM CDT

Exam Action 05/29/18 12:39 PM CDT

Exam Action 05/29/18 12:39 PM CDT

Exam Action 05/29/18 12:39 PM CDT

Exam Action 05/29/18 12:40 PM CDT

Exam Action 05/29/18 12:40 PM CDT

Exam Action 05/29/18 12:41 PM CDT

Exam Action 05/29/18 12:42 PM CDT

Auscultated right renal artery Auscultated right renal artery

Auscultated left iliac artery Auscultated left iliac artery

Auscultated right iliac artery Auscultated right iliac artery

Auscultated left femoral artery Auscultated left femoral artery

Auscultated right femoral artery Auscultated right femoral artery

Percussed left lower quadrant Percussed left lower quadrant

Percussed left upper quadrant Percussed left upper quadrant

Percussed right lower quadrant Percussed right lower quadrant

Percussed right upper quadrant Percussed right upper quadrant

Percussed right flank for CVA tenderness Percussed right flank for CVA tenderness

Percussed left flank for CVA tenderness Percussed left flank for CVA tenderness

Percussed spleen Percussed spleen

Percussed for liver span: 7 cm in the mid-clavicular line Percussed for liver span: 7 cm in the mid-clavicular line

Question 05/29/18 12:52 PM CDT

Question 05/29/18 12:52 PM CDT

Question 05/29/18 12:53 PM CDT

Question 05/29/18 12:54 PM CDT

Question 05/29/18 12:54 PM CDT

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Question 05/29/18 12:55 PM CDT

Question 05/29/18 12:55 PM CDT

How often do you use ibuprofen? (Clarified to how frequently do youHow often do you use ibuprofen? (Clarified to how frequently do you

take Advil.)take Advil.)

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 takeWhat is the name of antacid you take

I take the chewable Tums.

How often are you taking Tums?How often are you taking Tums?

I take them every few days. Just if the heartburn gets bad.

How many times a day do you take the antacid?How many times a day do you take the antacid?

I don't take them every day.

How many times do you chew a time? (No matching questionsHow many times do you chew a time? (No matching questions

found.)found.)

How many times do you chew How many times do you chew tumstums

I brush my teeth at least twice a day--every morning and at night.

How many times tums do you take at a timeHow many times tums do you take at a time

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?Do the Tums help with your pain?

Question 05/29/18 12:55 PM CDT

Educate 05/29/18 12:56 PM CDT

Question 05/29/18 12:56 PM CDT

Question 05/29/18 12:57 PM CDT

Question 05/29/18 12:57 PM CDT

Question 05/29/18 12:58 PM CDT

Question 05/29/18 12:58 PM CDT

Question 05/29/18 12:58 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 is important to follow the instructions on the bottle.

Sure, I think I understand what you mean.

How many times do you take at one timeHow many times do you take at one time

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 theDo the antacids relieve your pain (Clarified to Does taking the

antacids help.)antacids help.)

Yeah, they help. I try to only take them when the pain seems worse

than usual.

When did you last take Tums?When did you last take Tums?

Yesterday, after dinner.

Any new allergies to report?Any new allergies to report?

No, not that I know of.

Can you confirm your allergies? (No matching questions found.)Can you confirm your allergies? (No matching questions found.)

What are you allergic to?What are you allergic to?

I'm allergic to cats.

Question 05/29/18 1:03 PM CDT

Question 05/29/18 1:04 PM CDT

Question 05/29/18 1:06 PM CDT

Question 05/29/18 1:07 PM CDT

Question 05/29/18 1:07 PM CDT

Question 05/29/18 1:07 PM CDT

Question 05/29/18 1:07 PM CDT

Question 05/29/18 1:07 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?Where did you last use your flovent?

This morning, I had breakfast at home.

Any history of gastrointestinal disease? (Clarified to Have you hadAny history of gastrointestinal disease? (Clarified to Have you had

gastrointestinal disease?.)gastrointestinal disease?.)

I don't have like, diseases. But I've had this stomach pain for like, a

month.

History of GERD?History of GERD?

No.

Gastrointestinal surgery?Gastrointestinal surgery?

No.

History of appendicitis?History of appendicitis?

No.

History of cholecystitis?History of cholecystitis?

Not that I've heard of.

History of stomach cancer?History of stomach cancer?

Question 05/29/18 1:08 PM CDT

Question 05/29/18 1:08 PM CDT

Question 05/29/18 1:08 PM CDT

Question 05/29/18 1:08 PM CDT

Question 05/29/18 1:09 PM CDT

Question 05/29/18 1:09 PM CDT

Question 05/29/18 1:10 PM CDT

No.

History of liver disease? (Clarified to do you have liver disease.)History of liver disease? (Clarified to do you have liver disease.)

No, I've never had any problems with my liver.

Do you have kidney disease?Do you have kidney disease?

No. As far as I know, I've never had anything wrong with my kidneys.

Do you have history of bladder disease?Do you have history of bladder disease?

Not that I've heard of.

Do you have a history of ulcers?Do you have a history of ulcers?

No.

How often do you have a bowel movement?How often do you have a bowel movement?

Usually every other day.

Do you have pain during your bowel movements?Do you have pain during your bowel movements?

No.

Any blood in your bowel movements?Any blood in your bowel movements?

Um, no.

Question 05/29/18 1:13 PM CDT

Question 05/29/18 1:14 PM CDT

Question 05/29/18 1:14 PM CDT

Question 05/29/18 1:42 PM CDT

Question 05/29/18 1:43 PM CDT

Question 05/29/18 1:44 PM CDT

Question 05/29/18 1:44 PM CDT

I don't think so... My pee hasn't been red or anything.

Any incontinence? (Clarified to have you had accidents in theAny incontinence? (Clarified to have you had accidents in the

bathroom.)bathroom.)

No, I haven't had problems with that.

When was your last menstrual period?When was your last menstrual period?

I think it was just about a month ago.

Are you sexually active?Are you sexually active?

Um, not right now.

what did you have for breakfast?what did you have for breakfast?

This morning, I had toast with butter and honey, and some orange

juice.

What does your lunch consist of? (Clarified to what do you usuallyWhat does your lunch consist of? (Clarified to what do you usually

eat for lunch.)eat for lunch.)

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?What did you eat yesterday for breakfast?

I had a small bowl of cereal.

What did you have yesterday for lunch?What did you have yesterday for lunch?

I had a piece of pizza. It was someone's birthday at work, so they

ordered pizza for all of us.

Educate 05/29/18 1:45 PM CDT

Question 05/29/18 1:45 PM CDT

Educate 05/29/18 1:45 PM CDT

Question 05/29/18 1:46 PM CDT

Question 05/29/18 1:48 PM CDT

Educate 05/29/18 1:49 PM CDT

Question 05/29/18 1:50 PM CDT

The pizza may be contributing to your stomach painThe pizza may be contributing to your stomach pain

OK, I understand.

What did you have for dinner yesterday?What did you have for dinner yesterday?

Last night we had baked potatoes with broccoli and cheese soup on

them.

That is a pretty heavy meal that may upset your stomachThat is a pretty heavy meal that may upset your stomach

That makes sense.

How many meals do you typically eat a day ?How many meals do you typically eat a day?

I try to eat breakfast, lunch, and dinner. I usually have a snack

somewhere in there.

What do you typically eat for breakfast?What do you typically eat for breakfast?

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.

Those are very high in carbohydrates for breakfast are very high in carbohydrates for breakfast.

OK, I understand.

What do you typically eat for lunch?What do you typically eat for lunch?

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.

French fries and pretzels are high in calories and carbohydratesFrench fries and pretzels are high in calories and carbohydrates

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Gastrointestinal Transcript

Course: Diagnostic assessment (MSN610)

31 Documents
Students shared 31 documents in this course

University: Northern Kentucky University

Was this document helpful?
5/29/2018 Gastrointestinal | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3536206 1/28
Gastrointestinal Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Lab Pass
Started: May 29, 2018 | Patient Exam Time: 198 min
Transcript
Greet
05/29/18 10:20 AM
CDT
Question
05/29/18 10:20 AM
CDT
Question
05/29/18 10:24 AM
CDT
Question
05/29/18 10:26 AM
CDT
Question
05/29/18 10:35 AM
CDT
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Lifespan
Review Questions
Self-Reflection
Interview Questions (152)
Interview Questions (152) Statements (17)
Statements (17) Exam Actions (58)
Exam Actions (58)
Hello my name is Sara an FNP student and will be interviewing you
Hello my name is Sara an FNP student and will be interviewing you
today
today
Hey.
will you state your name (Clarified to what is your name.)
will you state your name (Clarified to what is your name.)
Tina Jones.
what is your date of birth
what is your date of birth
February 17th.
how old are you ?
how old are you ?
I'm 28.
what brought you in to the clinic today?
what brought you in to the clinic today?
I've been having this stomach pain for awhile. It keeps coming back,
and it really is starting to bother me.
All Lines (227)
All Lines (227)

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