Tina jones Gastrointestinal Shadow Health Transcript
|
tina jones gastrointestinal shadow health transcript
Hello. My name is xxxx. I will interview you and later do a physical exam.
|
Greet |
|
 |
Hey.
|
|
 |
What is your name?
|
Question |
|
Tina Jones.
|
|
|
What is you date of birth?
|
Question |
|
February 17th.
|
|
|
How old are you?
|
Question |
|
I’m 28.
|
|
|
What brings you to the clinic today?
|
Question |
|
I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me.
|
|
|
Sorry to hear that you are feeling bad
|
Empathize |
|
Thanks for understanding tina jones gastrointestinal shadow health transcript.
|
|
|
When did the pain start?
|
Question |
|
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 s the pain located?
|
Question |
|
It’s like… my upper stomach. Like right below my breastbone, in the middle.
|
|
|
Describe how the pain feels
|
Question |
|
Um, it feels like heartburn. But sometimes, if it’s bad, it’s sharper than that.
|
|
|
Does the pain increase?
|
Question |
|
Yeah, it’s getting worse over time. I get these stomach pains every day.
|
|
|
How many times a week are you getting the pain? (Clarified to How many times a week have you been having issues with abdominal pain?.)
|
Question |
|
Every time I eat it hurts a little, but 3 or 4 times a week, it’ll be a lot worse. (Clarified to how many times a week I have abdominal pain.)
|
|
|
Do you have the abdominal pain everyday?
|
Question |
|
Yeah, I’ve had stomach pain for awhile now.
|
|
|
when did the abdominal pain begin?
|
Question |
|
Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad.
|
|
|
How long does the pain last?
|
Question |
|
For a few hours after I eat.
|
|
|
How do you rate the pain on a scale of 0 to 10? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)
|
Question |
|
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.)
|
|
|
Is the pain crushing?
|
Question |
|
No.
|
|
|
Is the pain gnawing ?
|
Question |
|
No, it’s not like that.
|
|
|
Is the pain cramping tina jones gastrointestinal shadow health transcript?
|
Question |
|
No, it’s not like stomach cramps.
|
|
|
where is the pain located?
|
Question |
|
It’s like… my upper stomach. Like right below my breastbone, in the middle.
|
|
|
on what side of your stomach is the pain located?
|
Question |
|
No, it’s right in the center of my stomach, like between my belly button and my ribs.
|
|
|
do you have sharp pain in your lower abdomen?
|
Question |
|
No, it’s not at all like that. It’s in the middle of my stomach.
|
|
|
Am sorry you feel that
|
Empathize |
|
I appreciate you saying that.
|
|
|
does your pain occur after eating?
|
Question |
|
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?
|
Question |
|
Yes, large meals make the pain worse. [AUDIO COMING SOON]
|
|
|
do you eat spicy foods?
|
Question |
|
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 fatty foods?
|
Question |
|
Not too much. I mean, I like French fries and stuff, but I try not to eat them too often.
|
|
|
French fries are considered fatty foods, try cut down on them
|
Educate |
|
Alright, thanks for letting me know.
|
|
|
Is your pain worse when you bend over?
|
Question |
|
Yeah. It gets worse when I bend over — I noticed that at work.
|
|
|
sorry to hear that
|
Empathize |
|
Thanks for saying that.
|
|
|
Does it hurt when you lie flat?
|
Question |
|
Yeah.
|
|
|
Try not to bend over at work
|
Educate |
|
Thanks for telling me tina jones gastrointestinal shadow health transcript.
|
|
|
Is the pain better when you sit up? (Clarified to Does the pain improve when you sit up?.)
|
Question |
|
Usually, yeah. (Clarified to if my pain improves when I sit up.)
|
|
|
any decrease in appetite?
|
Question |
|
Yeah, I haven’t been wanting to eat lately.
|
|
|
Its important you take 3 meals a day
|
Educate |
|
OK, I understand.
|
|
|
Do you eat out?
|
Question |
|
I try not to eat out too much, but with my schedule I end up having to.
|
|
|
have you been eating smaller meals than usual?
|
Question |
|
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.
|
|
|
Any increase in burping? (Clarified to Have you been burping more than usual?.)
|
Question |
|
Yeah, that’s been happening after I eat. (Clarified to if I have been burping more than usual lately.)
|
|
|
what makes your stomach pain relieve? (Clarified to What makes the abdominal pain better?.)
|
Question |
|
I feel the best in-between meals. And sitting up on the couch seems to help. And sometimes I take an antacid. (Clarified to what makes the abdominal pain better.)
|
|
|
Sitting up position helps prevent stomach acid from coming up the esophagus.
|
Educate |
|
Sure, I think I understand what you mean.
|
|
|
What is the name of the antacid?
|
Question |
|
I take the chewable Tums.
|
|
|
How many chewable tums? (No matching questions found.)
|
Question |
|
How many chew able tums do you take in a day?
|
Question |
|
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 relieve your pain?
|
Question |
|
Yeah, they help. I try to only take them when the pain seems worse than usual.
|
|
|
Does use of antacid help?
|
Question |
|
Yeah, they help. I try to only take them when the pain seems worse than usual.
|
|
|
Does the pain change?
|
Question |
|
Yeah, it’s getting worse over time. I get these stomach pains every day.
|
|
|
Does the stomach pain come with nausea and vomiting?
|
Question |
|
No, I don’t feel nauseous.
|
|
|
does your pain cause vomiting? (No matching questions found.)
|
Question |
|
does the pain cause vomiting? (No matching questions found.)
|
Question |
|
is your abdomen tender?
|
Question |
|
No. My stomach pain’s not tender like that.
|
|
|
any cramping?
|
Question |
|
Yeah, I get cramps pretty bad.
|
|
|
Is your pain associated with gas?
|
Question |
|
I don’t think so. I haven’t been gassy lately.
|
|
|
are you passing gas?
|
Question |
|
No.
|
|
|
How is your bowel?
|
Question |
|
I guess I normally go once a day, or sometimes every other day.
|
|
|
What the bowel colour? (No matching questions found.)
|
Question |
|
What is your typical breakfast?
|
Question |
|
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.
|
|
|
what is your usual lunch?
|
Question |
|
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.
|
|
|
Try and avoid fatty foods such as chips and french fries, they are not healthy.
|
Educate |
|
That makes sense.
|
|
|
any flatus after eating? (No matching questions found.)
|
Question |
|
How often do you eat spicy foods?
|
Question |
|
Well, I used to eat spicy food sometimes, but in the last few weeks I can’t. It makes my stomach pain too bad tina jones gastrointestinal shadow health transcript.
|
|
|
Spicy foods can irritate the stomach lining.
|
Educate |
|
Alright, thanks for letting me know.
|
|
|
Are you having stomach pain now? (Clarified to Do you have stomach pain right now?.)
|
Question |
|
Only a little. (Clarified to if I have stomach pain right now.)
|
|
|
what tome of the day is the pain the worst?
|
Question |
|
I don’t think it’s a particular time of day. It just hurts the worst right after I eat.
|
|
|
Do you have allergies?
|
Question |
|
Yeah, I’m allergic to cats.
|
|
|
Do you have gastrointestinal disease?
|
Question |
|
I don’t have like, diseases. But I’ve had this stomach pain for like, a month.
|
|
|
have you ever had gastrointestinal surgery?
|
Question |
|
No.
|
|
|
any past history of appendicitis?
|
Question |
|
No.
|
|
|
have you ever had cholecystitis?
|
Question |
|
Not that I’ve heard of.
|
|
|
Any history of stomach cancer?
|
Question |
|
No.
|
|
|
what about liver disease? (No matching questions found.)
|
Question |
|
Any history of liver disease?
|
Question |
|
No, I’ve never had any problems with my liver.
|
|
|
any history of ulcers?
|
Question |
|
No.
|
|
|
any history of bladder disease?
|
Question |
|
No, I never have.
|
|
|
do you experience pain during bowel movements?
|
Question |
|
No.
|
|
|
Any bloody or tarry stools?
|
Question |
|
Um, no.
|
|
|
any mucus ins stool? (Clarified to Have you had mucus in your stool?.)
|
Question |
|
Ew. No. (Clarified to if there has been mucus in my stool.)
|
|
|
Any changes in bowel movements pattern?
|
Question |
|
No, everything’s been normal in that department.
|
|
|
Do you have increased urination?
|
Question |
|
Yeah, but I’ve been drinking more water.
|
|
|
drinking water is good for you
|
Educate |
|
That makes sense.
|
|
|
What is the colour of your urine?
|
Question |
|
Um, light yellow or almost clear? The regular color.
|
|
|
Do you have pain during urination?
|
Question |
|
No.
|
|
|
do you experience nocturia? (No matching questions found.)
|
Question |
|
do you experience nocturia?do you urinate more than usual at night?
|
Question |
|
Yeah, but I’ve been drinking more water.
|
|
|
does your urine have blood?
|
Question |
|
I don’t think so… My pee hasn’t been red or anything.
|
|
|
when was your last period?
|
Question |
|
I think it was just about a month ago tina jones gastrointestinal shadow health transcript.
|
|
|
do you have stomach pain during you periods?
|
Question |
|
Yeah, I get cramps pretty bad.
|
|
|
are you sexually active?
|
Question |
|
Um, not right now.
|
|
|
when was your last meal?
|
Question |
|
This morning, I had breakfast at home.
|
|
|
what did you have for breakfast?
|
Question |
|
This morning, I had toast with butter and honey, and some orange juice.
|
|
|
what did you have for dinner yesterday?
|
Question |
|
Last night we had baked potatoes with broccoli and cheese soup on them.
|
|
|
what did you have for lunch yesterday?
|
Question |
|
I had a piece of pizza. It was someone’s birthday at work, so they ordered pizza for all of us.
|
|
|
what was your breakfast yesterday?
|
Question |
|
I had a small bowl of cereal.
|
|
|
What is your typical diet?
|
Question |
|
It’s pretty good, I think. I’m not a huge health nut or anything.
|
|
|
what is your typical breakfast? ORDER SHADOW HEALTH ASSESSMENT HELP HERE |
Question |
|
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.
|
|
|
what is your typical dinner?
|
Question |
|
Oh, we try to make something easy. We eat a lot of frozen chicken breasts. We do hamburgers that we make at home every so often. We make sure we have a vegetable, and we eat a lot of potatoes. And we usually have rolls or something.
|
|
|
what is your typical lunch?
|
Question |
|
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.
|
|
|
how many meals do you have in a day?
|
Question |
|
I try to eat breakfast, lunch, and dinner. I usually have a snack somewhere in there.
|
|
|
Do you take alcohol? (No matching questions found.)
|
Question |
|
Do you drink alcohol?
|
Question |
|
Not lately, but I do every so often.
|
|
|
how often do you drink alcohol?
|
Question |
|
Very rarely.
|
|
|
how many beers do drink per sitting?
|
Question |
|
Never any more than 2 or 3.
|
|
|
That moderate drinking which is ok
|
Educate |
|
Thanks for telling me.
|
|
|
Do you take soda? (No matching questions found.)
|
Question |
|
Do you drink soda?
|
Question |
|
Yeah, I drink diet Coke.
|
|
|
How many glasses of water do you take daily?
|
Question |
|
Probably… 6 or 8 glasses? I drink a lot of water.
|
|
|
Have you had food poisoning?
|
Question |
|
I’ve had food poisoning when I was a kid, and this isn’t anything like that.
|
|
|
Have you had recent travel?
|
Question |
|
No. I’ve been here in Shadowville working my butt off!
|
|
|
Do you use illicit drugs tina jones gastrointestinal shadow health transcript?
|
Question |
|
Well, I used to smoke pot. . . but I don’t do that anymore.
|
|
|
do you smoke cigarette
|
Question |
|
No, I’ve never smoked a cigarette in my life.
|
|
|
Great! Smoking and drugs are not good for you
|
Educate |
|
OK, I understand.
|
|
|
are you bloated?
|
Question |
|
No, I don’t feel bloated.
|
|
|
Do you have sore throat?
|
Question |
|
No, my throat doesn’t hurt.
|
|
|
Are you coughing?
|
Question |
|
No, I haven’t been coughing.
|
|
|
do you have difficulty breathing?
|
Question |
|
No, my breathing has been fine.
|
|
|
do you have chest pain?
|
Question |
|
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.
|
|
|
has you sense of taste changed?
|
Question |
|
No, I can taste everything fine.
|
|
|
Any family history of colon cancer?
|
Question |
|
Um, Grandpa Jones died of colon cancer.
|
|
|
am sorry to hear that
|
Empathize |
|
Thanks.
|
|
|
do you have a family history of GERD?
|
Question |
|
No.
|
|
|
Do you have a family history of ibs?
|
Question |
|
No, I haven’t heard anything about that.
|
|
|
Do you have a family history of Cholecystitis?
|
Question |
|
Not that I’ve heard of.
|
|
|
Any family history of liver disease?
|
Question |
|
No, nobody’s had anything happen with their liver that I know of.
|
|
|
Any family history of bladder disease?
|
Question |
|
Not that I’ve heard of.
|
|
|
Any family history of kidney disease?
|
Question |
|
No, nobody’s had that.
|
|
|
What are your allergies?
|
Question |
|
I’m allergic to cats.
|
|
|
what happens when you are around cats?
|
Question |
|
Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up tina jones gastrointestinal shadow health transcript.
|
|
|
Are you allergic to dust?
|
Question |
|
Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.
|
|
|
are you allergic to penicillin?
|
Question |
|
Yes.
|
|
|
what do you take for asthma?
|
Question |
|
I have my Proventil inhaler, and then my daily Flovent inhaler, too.
|
|
|
what is the dosage of the proventil?
|
Question |
|
I haven’t used my rescue inhaler in three months — not since I started the daily Flovent one.
|
|
|
when did you last use you flovent? (No matching questions found.)
|
Question |
|
how consistent are your bowel movements? (Clarified to How often do you have a bowel movement?.)
|
Question |
|
Usually every other day. (Clarified to how often I have a bowel movement.)
|
|
|
Do you get up in the middle of the night to urinate?
|
Question |
|
Yeah, I definitely get up more than once during the night.
|
|
|
how many meals do you typically eat in a day?
|
Question |
|
I try to eat breakfast, lunch, and dinner. I usually have a snack somewhere in there.
|
|
|
what did you have for dinner last night?
|
Question |
|
Last night we had baked potatoes with broccoli and cheese soup on them.
|
|
|
ok. such a heavy meal may upset your stomach
|
Educate |
|
Sure, I think I understand what you mean.
|
|
|
when did you last drink alcohol?
|
Question |
|
At least 2 weeks ago. I have been staying at from it.
|
|
|
do you smoke pot?
|
Question |
|
No, not since… not in like 6 or 7 years.
|
|
|
its good that you quit
|
Educate |
|
That makes sense.
|
|
|
Any fever?
|
Question |
|
No. No fever.
|
|
|
Any chills?
|
Question |
|
No, no chills.
|
|
|
Any fatigue?
|
Question |
|
No, I don’t feel tired tina jones gastrointestinal shadow health transcript.
|
|
|
any night sweats?
|
Question |
|
No.
|
|
|
do you have anxiety?
|
Question |
|
Not too much — I can get a little anxious and stressed because I’m busy and I work hard. I might have some anxiety lately. Especially since I’d like to get this heartburn fixed.
|
|
|
am sorry to hear that
|
Empathize |
|
I appreciate you telling me that.
|
|
|
any feelings of stress?
|
Question |
|
Ha. Yeah, I do feel stressed out. I’m almost done with school in a few months, and so I’m job-hunting. Plus I work. It’s a lot right now. And I’d like to figure out what’s going on with my stomach, too.
|
|
|
How do you cope with your stress?
|
Question |
|
I just keep my head down and work on one thing at a time. I try to get a lot of sleep, too, if I’m especially stressed. And my mom is really supportive, so just talking with her always makes me feel better.
|
|
|
we should help you get off stress and anxiety
|
Educate |
|
Thanks for telling me.
|
|
|
Any nausea?
|
Question |
|
No, I’m fine.
|
|
|
Any vomiting?
|
Question |
|
No.
|
|
|
Any constipation?
|
Question |
|
I don’t have that problem.
|
|
|
any medications that you use?
|
Question |
|
I have a daily inhaler. And I’ve been taking antacid chews sometimes for my stomach, too.
|
|
|
what is your highest level of education?
|
Question |
|
Well, I’m finishing up my Bachelor’s degree right now.
|
|
|
what course are you pursuing? (No matching questions found.)
|
Question |
|
what is your major?
|
Question |
|
I’m going to get my bachelor’s in accounting tina jones gastrointestinal shadow health transcript.
|
|
|
Are you working?
|
Question |
|
I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
|
|
|
great, how is the work environment? (Clarified to How is work going?.)
|
Question |
|
I like my job now, but once I graduate I’d really like to get a job at an accounting firm. I want my job to teach me new things and allow for real advancement. (Clarified to how work is.)
|
|
|
who do you live with?
|
Question |
|
Right now I live back at home with my mom and my sister.
|
|
|
Tested skin turgor on forearm
|
Exam Action |
|
Inspected right side of abdomen
|
Exam Action |
|
Inspected front of abdomen
|
Exam Action |
|
Inspected left side of abdomen
|
Exam Action |
|
Auscultated breath sounds in anterior right middle lobe
|
Exam Action |
|
Auscultated breath sounds in anterior right upper lobe
|
Exam Action |
|
Auscultated breath sounds in anterior right lower lobe
|
Exam Action |
|
Auscultated breath sounds in anterior left mid-chest (upper lobe)
|
Exam Action |
|
Auscultated breath sounds in anterior left upper lobe
|
Exam Action |
|
Auscultated breath sounds in anterior left lower lobe
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe on side
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe near spine
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe
|
Exam Action |
|
Auscultated breath sounds in posterior left mid-back (lower lobe)
|
Exam Action |
|
Auscultated breath sounds in posterior left lower lobe near spine
|
Exam Action |
|
Auscultated breath sounds in posterior right mid-back (lower lobe)
|
Exam Action |
|
Auscultated breath sounds in posterior right lower lobe near spine
|
Exam Action |
|
Auscultated breath sounds in posterior right lower lobe on side
|
Exam Action |
|
Auscultated breath sounds in posterior right upper lobe
|
Exam Action |
|
Auscultated breath sounds in posterior left upper lobe
|
Exam Action |
|
Auscultated breath sounds in posterior right lower lobe
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated mitral area with the bell tina jones gastrointestinal shadow health transcript
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated right upper quadrant
|
Exam Action |
|
Auscultated left lower quadrant
|
Exam Action |
|
Auscultated left upper quadrant
|
Exam Action |
|
Auscultated right lower quadrant
|
Exam Action |
|
Auscultated aorta in abdomen
|
Exam Action |
|
Auscultated right lower quadrant
|
Exam Action |
|
Auscultated right upper quadrant
|
Exam Action |
|
Auscultated left upper quadrant
|
Exam Action |
|
Auscultated aorta in abdomen
|
Exam Action |
|
Auscultated left renal artery
|
Exam Action |
|
Auscultated right renal artery
|
Exam Action |
|
Auscultated left iliac artery
|
Exam Action |
|
Auscultated right iliac artery
|
Exam Action |
|
Auscultated right femoral artery
|
Exam Action |
|
Auscultated left femoral artery
|
Exam Action |
|
Auscultated right femoral artery
|
Exam Action |
|
Percussed right upper quadrant
|
Exam Action |
|
Percussed left upper quadrant
|
Exam Action |
|
Percussed right lower quadrant
|
Exam Action |
|
Percussed left flank for CVA tenderness
|
Exam Action |
|
Percussed right flank for CVA tenderness
|
Exam Action |
|
Percussed spleen
|
Exam Action |
|
Percussed for liver span: 7 cm in the mid-clavicular line
|
Exam Action |
|
Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
|
Exam Action |
|
Palpated right upper quadrant with deep pressure: No masses
|
Exam Action |
|
Palpated left lower quadrant with deep pressure: No masses
|
Exam Action |
|
Palpated right upper quadrant with deep pressure: No masses
|
Exam Action |
|
Palpated left upper quadrant with deep pressure: No masses
|
Exam Action |
|
Palpated right lower quadrant: with deep pressure: No masses
|
Exam Action |
|
Palpated liver: Palpable 1 cm below right costal margin
|
Exam Action |
|
Palpated for spleen: Not palpable
|
Exam Action |
|
Palpated for right kidney: Not palpable
|
Exam Action |
|
Palpated for left kidney: Not palpable
|
Exam Action |