GI A4: Shadow Health

GI A4: Shadow Health

GI A4: Shadow Health

Professional Development

  • Write a 500-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
    • What went well in your assessment?
    • What did not go so well? What will you change for your next assessment?
    • What findings did you uncover?
    • What questions yielded the most information? Why do you think these were effective?
    • What diagnostic tests would you order based on your findings?
    • What differential diagnoses are you currently considering?
    • What patient teaching were you able to complete? What additional patient teaching is needed?
    • Would you prescribe any medications at this point? Why or why not? If so, what?
    • How did your assessment demonstrate sound critical thinking and clinical decision making?

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  • attachmentGastrointestinaltranscript.pdf
  • attachmentGIdocumentation.pdf
  • attachmentGIturnitin.pdf

Gastrointestinal Results | Completed Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313476/)

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Transcript

Started: Apr 08, 2020 | Total Time: 48 min

Gree 04/08/20 5:29 PM MD

Question 04/08/20 5:29 PM MD

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Empathize 04/08/20 5:29 PM MD

Educate 04/08/20 5:29 PM MD

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Your Results Lab Pass (/assignment_attempts/6541639/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Interview Questions (104) Statements (26) Exam Actions (52)

Hello Miss Jones my name is Doris and I’m here to see you again

Hey.

Maya just verify your name and date of birth (Clarified to What is your name and birthday?.)

My name’s Tina Jones, and my birthday’s February 17th. (Clarified to what is my name and date of birth.)

What brings you in today

I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me.

I’m sorry that must be hard for you

I appreciate you saying that.

Let’s see what we can figure out here as I go to your history

Sure, I think I understand what you mean.

Me ask 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.

Is it getting worse

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https://aspen.shadowhealth.com/assignments/313476/
https://aspen.shadowhealth.com/assignment_attempts/6541639/lab_pass.pdf

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

Can I ask how often are you having the pain

It’s every time I eat.

How many episodes in a day (No matching questions found.)

IS THAT 3 TIMES A DAY (No matching questions found.)

Does this happen every day (No matching questions found.)

Is it pain daily

Yeah, I notice it every day. It seems like… 3 or 4 times a week, I’ll have an episode that’s worse.

How long does it pain last

For a few hours after I eat.

What makes it worse

Eating seems to cause it.

What makes it better

Talking to friends or family and going to church always help me feel less stressed–just feeling supported and like someone cares.

How strong is your pain from 1 to 10 (Clarified to How severe is your pain?.)

Right now, I don’t really notice anything, but it can get bad after I eat. (Clarified to how severe my pain is.)

From 1 to 10 10 being the worst what is it (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)

Right now, it’s like a 1 or 2. But after I eat, it’s like a. . . 5? (Clarified to how I would rate my pain on a scale.)

Does it help when you’re sitting up (Clarified to Does the pain improve when you sit up?.)

Usually, yeah. (Clarified to if my pain improves when I sit up.)

Can you describe the pain

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

Do you have chest pain

No, I’m not having chest pain. The pain I’m feeling is lower, like right in the middle of my torso. . . above my stomach, but below my ribs.

Does it feel cramping

No, it’s not like stomach cramps.

Does it hurt to touch your belly

Yes. Every time I eat it hurts. I’ve been eating less because I don’t like being in pain.

Have you lost weight

No, I don’t think so.

Where’s the location of the pain

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

Does it radiate to your back (No matching questions found.)

Does it radiate to your SHOULDER (No matching questions found.)

Does it radiate to your back (No matching questions found.)

DOES THE PAIN RADIATE TO YOUR ARM

No, it’s right in the center of my stomach, like between my belly button and my ribs.

Let’s review your diet

Thanks for telling me.

May I ask what food do you eat (No matching questions found.)

Give me a diary of your food intake (No matching questions found.)

Does the pain get worse with large meals (Clarified to Do large meals make the pain worse?.)

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Yes, large meals make the pain worse. [AUDIO COMING SOON] (Clarified to if large meals make the pain worse.)

Do you eat spicy food

Well, I used to eat spicy food sometimes, but in the last few weeks I can’t. It makes my stomach pain too bad.

Do you eat a lot of fried foods

Not too much. I mean, I like French fries and stuff, but I try not to eat them too often.

How’s your appetite

I haven’t been wanting to eat lately.

Why don’t you want to eat

It seems like if I eat too much, that’s what makes my stomach pain the worst.

Do you have any burping

Yeah, that’s been happening after I eat.

What food are you eating

I don’t have any food allergies that I know of.

What medication are you taking right now

I have a daily inhaler. And I’ve been taking antacid chews sometimes for my stomach, too.

Are you taking any over-the-counter medication

I’ve been taking antacids lately — chewable ones.

Does it help (Clarified to Does taking the antacids help?.)

Yeah, they help. I try to only take them when the pain seems worse than usual. (Clarified to if the antacids help.)

How often are you taking antacids

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

Are you taking any ibuprofen

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Yeah, I still take it for cramps.

How often are you taking that (Clarified to How often do you take over the counter medication?.)

I take them every few days. Just if the heartburn gets bad. (Clarified to how often I take over the counter medication.)

Do you have drug allergies

Yeah, I’m allergic to penicillin.

What happens with Penicillin

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.

I’m glad you know that you’re allergic to penicillin

Alright, thanks for letting me know.

Do you have any gastrointestinal problems

Yeah, I’ve had stomach pain for awhile now.

Have you had ulcers

No.

Have you had any GERD

I’m not really sure what GERD is. I’ve never been diagnosed with it, or anything. [AUDIO COMING SOON]

Have you had any GI surgery

No.

Have you had any appendicitis

No.

Have you had any problems with your gallbladder

No, as far as I know my gallbladder’s never had any problems.

That’s good to hear

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OK, I understand.

Have you had any stomach cancer (Clarified to Have you had stomach cancer?.)

No. (Clarified to if I have had stomach cancer.)

Do you have family history of stomach cancer

The only cancer that I know of in our family is colon cancer–Grandpa Jones died of that.

Have you any problems with your bladder

No, I never have.

How often do you have a bowel movement

Usually every other day.

Is your stool bloody

Um, no.

Do you have mucus in your stool

Ew. No.

What is the consistency of your stool (Clarified to Can you describe your stool?.)

Uh… usually light or dark brown, I guess? (Clarified to what my stool looks like.)

Do you have trouble peeing

No, I can pee fine.

Do you pee frequently

Yeah, I definitely get up more than once during the night.

Do you have painful urination

No.

Is your urine clear

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Um, light yellow or almost clear? The regular color.

Do you have accidentally pee on yourself (Clarified to Have you ever peed yourself?.)

Definitely not. (Clarified to if I have ever had urinary incontinence.)

When was your last menstrual period

I think it was just about a month ago.

Are you sexually active

Um, not right now.

Can you tell me what you have for breakfast (Clarified to What did you eat for breakfast today?.)

This morning, I had toast with butter and honey, and some orange juice. (Clarified to what I ate for breakfast today.)

Can you tell me your diet within the 24 hour period (Clarified to What do you eat in an average day?.)

Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to what I typically eat in a day.)

What did you have for lunch yesterday

I had a piece of pizza. It was someone’s birthday at work, so they ordered pizza for all of us.

What did you have for dinner

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

Sounds like you have a lot of carbs in your diet maybe we should talk about that later

That makes sense.

Do you drink alcohol

Not lately, but I do every so often.

How often do you drink alcohol

Very rarely.

How many drinks in a setting

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Never any more than 2 or 3.

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