Tina Jones _ Gastrointestinal Results_Turned In | NR 509 Gastrointestinal_Transcript

Gastrointestinal Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results L La ab b P Pa as ss s 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 I In nt te er rv viie ew w Q Qu ue es st tiio on ns s ( (1 15 52 2) ) S St ta at te em me en nt ts s ( (1 17 7) ) E Ex xa am m A Ac ct tiio on ns s ( (5 58 8) ) Hello my name is Sara an FNP student and will be interviewing you today Hey. will you state your name (Clarified to what is your name.) Tina Jones. what is your date of birth February 17th. how old are you ? I'm 28. 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. A Allll L Liin ne es s ( (2 22 27 7) )5/29/2018 Gastrointestinal | Completed | Shadow Health 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 bad Thanks for understanding. 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? 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? It's like... my upper stomach. Like right below my breastbone, in the middle. 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? 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?.) Yeah, it's getting worse over time. I get these stomach pains every day. How many times a week are you getting this PAIN5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 11:01 AM CDT Question 05/29/18 11:03 AM CDT Question 05/29/18 11:04 AM CDT Question 05/29/18 11:07 AM CDT Question 05/29/18 11:07 AM CDT Question 05/29/18 11:08 AM CDT Question 05/29/18 11:09 AM CDT Question 05/29/18 11:09 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.) 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?.) 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? It starts pretty quickly after I finish eating. Like within ten or fifteen minutes. How long does the pain last? For a few hours after I eat. Will you rate your pain on a Pain Scale 0 out of 10 Right now, it's like a 1 or 2. But after I eat, it's like a. . . 5? Rate your pain when lying down? 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?5/29/2018 Gastrointestinal | Completed | Shadow Health 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? No, it's not like that. Is the pain cramping? No, it's not like stomach cramps. Does your abdomen tender to touch? No. My stomach pain's not tender like that. Where is your pain located It's like... my upper stomach. Like right below my breastbone, in the middle. 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? No, it's right in the center of my stomach, like between my belly button and my ribs. Shoulder pain? No.5/29/2018 Gastrointestinal | Completed | Shadow Health 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? My back feels fine. 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? No -- my pain is like, on my front. In the middle of my 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.) 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 in 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 bad Thanks for saying that. Your pain occurs after eating?5/29/2018 Gastrointestinal | Completed | Shadow Health Question 05/29/18 12:04 PM CDT Question 05/29/18 12:04 PM CDT Question 05/29/18 12:04 PM CDT Educate 05/29/18 12:05 PM CDT Question 05/29/18 12:05 PM CDT Empathize 05/29/18 12:05 PM CDT Question 05/29/18 12:06 PM CDT Educate 05/29/18 12:07 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? 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.) 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 Alright, thanks for letting me know. Is the pain worse when you bend over? Yeah. It gets worse when I bend over -- I noticed that at work. Sorry to hear that I appreciate you saying that. Does it hurt when you lie flat Yeah. Try to refrain from bending over at work5/29/2018 Gastrointestinal | Completed | Shadow Health 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? No, it's gotten worse and worse over time. 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? Usually, yeah. Any decrease in appetite? Yeah, I haven't been wanting to eat lately. It is important that you still eat 3 times a day That makes sense. You eat out? I try not to eat out too much, but with my schedule I end up having to - - - - Continued