NR 509 Advanced Health Assessment Gastrointestinal

5/29/2018 Gastrointestinal | Completed | Shadow Health


Gastrointestinal Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Overview
Transcript
Transcript
Started: May 29, 2018 | Patient Exam Time: 198 min
Subjective Data Collection
All Lines (227) Interview Questions (152) Statements (17) Exam Actions (58)
Objective Data Collection
Greet
Education & Empathy Hello my name is Sara an FNP student and will be interviewing you
05/29/18 10:20 AM
today
CDT
Documentation

Lifespan
Hey.
Review Questions

Question
Self-Reflection
will you state your name (Clarified to what is your name.) 05/29/18 10:20 AM
CDT



Tina Jones.


Question
what is your date of birth 05/29/18 10:24 AM
CDT



February 17th.


Question
how old are you ? 05/29/18 10:26 AM
CDT



I'm 28.


Question
what brought you in to the clinic today? 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.




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,5/29/2018 Gastrointestinal | Completed | Shadow Health

Sorry you are feeling so bad Empathize
05/29/18 10:38 AM
CDT



Thanks for understanding.


Question
when do you notice the pain? (Clarified to when does the pain start.) 05/29/18 10:41 AM
CDT


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


Question
when did the pain start? 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.


Question
Where is the pain located? 05/29/18 10:43 AM
CDT


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


Question
describe how the pain feels? 05/29/18 10:44 AM
CDT


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


Question
Does the pain increase? 05/29/18 11:00 AM
CDT


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


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




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, 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.


Question
do you have this pain every day? (Clarified to Do you have
05/29/18 11:03 AM
abdominal pain every day.)
CDT


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


Question
when does your abdominal pain begin (Clarified to When did the
05/29/18 11:04 AM
abdominal discomfort begin?.)
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.


Question
When does the pain begin? 05/29/18 11:07 AM
CDT


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


Question
How long does the pain last? 05/29/18 11:07 AM
CDT



For a few hours after I eat.


Question
Will you rate your pain on a Pain Scale 0 out of 10 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?


Question
Rate your pain when lying down? 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




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