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NR 509 Gastrointestinal | Transcript
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NR 509 Gastrointestinal | Transcript
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5/29/2018 Gastrointestinal | Completed | Shadow HealthGastrointestinal 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.
https://chamberlain.shadowhealth.com/assignment_attempts/3536206 1/28
,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
https://chamberlain.shadowhealth.com/assignment_attempts/3536206 3/28
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