tina jones gastrointestinal shadow health transcript – OnlineNursingPapers

Hello. My name is xxxx. I will interview you and later do a physical exam.

Greet07/05/20 10:03 PM CDT

Hey.

What is your name?

Question07/05/20 10:03 PM CDT

Tina Jones.

What is you date of birth?

Question07/05/20 10:04 PM CDT

February 17th.

How old are you?

Question07/05/20 10:05 PM CDT

I’m 28.

What brings you to the clinic today?

Question07/05/20 10:05 PM CDT

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

Empathize07/05/20 10:05 PM CDT

Thanks for understanding.

When did the pain start?

Question07/05/20 10:06 PM 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.

Where s the pain located?

Question07/05/20 10:06 PM CDT

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

Describe how the pain feels

Question07/05/20 10:06 PM CDT

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

Does the pain increase?

Question07/05/20 10:06 PM CDT

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?.)

Question07/05/20 10:07 PM CDT

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?

Question07/05/20 10:08 PM CDT

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

when did the abdominal pain begin?

Question07/05/20 10:09 PM 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.

How long does the pain last?

Question07/05/20 10:09 PM CDT

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?.)

Question07/05/20 10:10 PM CDT

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?

Question07/05/20 10:10 PM CDT

No.

Is the pain gnawing ?

Question07/05/20 10:11 PM CDT

No, it’s not like that.

Is the pain cramping?

Question07/05/20 10:11 PM CDT

No, it’s not like stomach cramps.

where is the pain located?

Question07/05/20 10:11 PM CDT

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

on what side of your stomach is the pain located?

Question07/05/20 10:12 PM CDT

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?

Question07/05/20 10:13 PM CDT

No, it’s not at all like that. It’s in the middle of my stomach.

Am sorry you feel that

Empathize07/05/20 10:14 PM CDT

I appreciate you saying that.

does your pain occur after eating?

Question07/05/20 10:14 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?

Question07/05/20 10:15 PM CDT

Yes, large meals make the pain worse. [AUDIO COMING SOON]

do you eat spicy foods?

Question07/05/20 10:15 PM CDT

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?

Question07/05/20 10:16 PM CDT

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

Educate07/05/20 10:17 PM CDT

Alright, thanks for letting me know.

Is your pain worse when you bend over?

Question07/05/20 10:17 PM CDT

Yeah. It gets worse when I bend over — I noticed that at work.

sorry to hear that

Empathize07/05/20 10:18 PM CDT

Thanks for saying that.

Does it hurt when you lie flat?

Question07/05/20 10:18 PM CDT

Yeah.

Try not to bend over at work

Educate07/05/20 10:18 PM CDT

Thanks for telling me.

Is the pain better when you sit up? (Clarified to Does the pain improve when you sit up?.)

Question07/05/20 10:19 PM CDT

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

any decrease in appetite?

Question07/05/20 10:20 PM CDT

Yeah, I haven’t been wanting to eat lately.

Its important you take 3 meals a day

Educate07/05/20 10:20 PM CDT

OK, I understand.

Do you eat out?

Question07/05/20 10:20 PM CDT

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?

Question07/05/20 10:21 PM CDT

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?.)

Question07/05/20 10:22 PM CDT

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?.)

Question07/05/20 10:23 PM CDT

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.

Educate07/05/20 10:25 PM CDT

Sure, I think I understand what you mean.

What is the name of the antacid?

Question07/05/20 10:25 PM CDT

I take the chewable Tums.

How many chewable tums? (No matching questions found.)

Question07/05/20 10:25 PM CDT

How many chew able tums do you take in a day?

Question07/05/20 10:26 PM CDT

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?

Question07/05/20 10:27 PM CDT

Yeah, they help. I try to only take them when the pain seems worse than usual.

Does use of antacid help?

Question07/05/20 10:27 PM CDT

Yeah, they help. I try to only take them when the pain seems worse than usual.

Does the pain change?

Question07/05/20 10:28 PM CDT

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

Does the stomach pain come with nausea and vomiting?

Question07/05/20 10:28 PM CDT

No, I don’t feel nauseous.

does your pain cause vomiting? (No matching questions found.)

Question07/05/20 10:29 PM CDT

does the pain cause vomiting? (No matching questions found.)

Question07/05/20 10:29 PM CDT

is your abdomen tender?

Question07/05/20 10:30 PM CDT

No. My stomach pain’s not tender like that.

any cramping?

Question07/05/20 10:30 PM CDT

Yeah, I get cramps pretty bad.

Is your pain associated with gas?

Question07/05/20 10:31 PM CDT

I don’t think so. I haven’t been gassy lately.

are you passing gas?

Question07/05/20 10:31 PM CDT

No.

How is your bowel?

Question07/05/20 10:31 PM CDT

I guess I normally go once a day, or sometimes every other day.

What the bowel colour? (No matching questions found.)

Question07/05/20 10:32 PM CDT

What is your typical breakfast?

Question07/05/20 10:33 PM CDT

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?

Question07/05/20 10:33 PM CDT

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.

Educate07/05/20 10:35 PM CDT

That makes sense.

any flatus after eating? (No matching questions found.)

Question07/05/20 10:35 PM CDT

How often do you eat spicy foods?

Question07/05/20 10:36 PM CDT

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

Spicy foods can irritate the stomach lining.

Educate07/05/20 10:36 PM CDT

Alright, thanks for letting me know.

Are you having stomach pain now? (Clarified to Do you have stomach pain right now?.)

Question07/05/20 10:37 PM CDT

Only a little. (Clarified to if I have stomach pain right now.)

what tome of the day is the pain the worst?

Question07/05/20 10:37 PM CDT

I don’t think it’s a particular time of day. It just hurts the worst right after I eat.

Do you have allergies?

Question07/05/20 10:39 PM CDT

Yeah, I’m allergic to cats.

Do you have gastrointestinal disease?

Question07/05/20 10:39 PM CDT

I don’t have like, diseases. But I’ve had this stomach pain for like, a month.

have you ever had gastrointestinal surgery?

Question07/05/20 10:40 PM CDT

No.

any past history of appendicitis?

Question07/05/20 10:40 PM CDT

No.

have you ever had cholecystitis?

Question07/05/20 10:41 PM CDT

Not that I’ve heard of.

Any history of stomach cancer?

Question07/05/20 10:42 PM CDT

No.

what about liver disease? (No matching questions found.)

Question07/05/20 10:42 PM CDT

Any history of liver disease?

Question07/05/20 10:43 PM CDT

No, I’ve never had any problems with my liver.

any history of ulcers?

Question07/05/20 10:43 PM CDT

No.

any history of bladder disease?

Question07/05/20 10:43 PM CDT

No, I never have.

do you experience pain during bowel movements?

Question07/05/20 10:44 PM CDT

No.

Any bloody or tarry stools?

Question07/05/20 10:44 PM CDT

Um, no.

any mucus ins stool? (Clarified to Have you had mucus in your stool?.)

Question07/05/20 10:44 PM CDT

Ew. No. (Clarified to if there has been mucus in my stool.)

Any changes in bowel movements pattern?

Question07/05/20 10:45 PM CDT

No, everything’s been normal in that department.

Do you have increased urination?

Question07/05/20 10:45 PM CDT

Yeah, but I’ve been drinking more water.

drinking water is good for you

Educate07/05/20 10:46 PM CDT

That makes sense.

What is the colour of your urine?

Question07/05/20 10:46 PM CDT

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

Do you have pain during urination?

Question07/05/20 10:47 PM CDT

No.

do you experience nocturia? (No matching questions found.)

Question07/05/20 10:48 PM CDT

do you experience nocturia?do you urinate more than usual at night?

Question07/05/20 10:49 PM CDT

Yeah, but I’ve been drinking more water.

does your urine have blood?

Question07/05/20 10:50 PM CDT

I don’t think so… My pee hasn’t been red or anything.

when was your last period?

Question07/05/20 10:51 PM CDT

I think it was just about a month ago.

do you have stomach pain during you periods?

Question07/05/20 10:51 PM CDT

Yeah, I get cramps pretty bad.

are you sexually active?

Question07/05/20 10:52 PM CDT

Um, not right now.

when was your last meal?

Question07/05/20 10:52 PM CDT

This morning, I had breakfast at home.

what did you have for breakfast?

Question07/05/20 10:53 PM CDT

This morning, I had toast with butter and honey, and some orange juice.

what did you have for dinner yesterday?

Question07/05/20 10:53 PM CDT

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

what did you have for lunch yesterday?

Question07/05/20 10:53 PM CDT

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?

Question07/05/20 10:54 PM CDT

I had a small bowl of cereal.

What is your typical diet?

Question07/05/20 10:55 PM CDT

It’s pretty good, I think. I’m not a huge health nut or anything.

what is your typical breakfast?

Question07/05/20 10:55 PM CDT

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?

Question07/05/20 10:55 PM CDT

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?

Question07/05/20 10:56 PM CDT

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?

Question07/05/20 10:56 PM CDT

I try to eat breakfast, lunch, and dinner. I usually have a snack somewhere in there.

Do you take alcohol? (No matching questions found.)

Question07/05/20 10:56 PM CDT

Do you drink alcohol?

Question07/05/20 10:57 PM CDT

Not lately, but I do every so often.

how often do you drink alcohol?

Question07/05/20 10:57 PM CDT

Very rarely.

how many beers do drink per sitting?

Question07/05/20 10:57 PM CDT

Never any more than 2 or 3.

That moderate drinking which is ok

Educate07/05/20 10:58 PM CDT

Thanks for telling me.

Do you take soda? (No matching questions found.)

Question07/05/20 10:58 PM CDT

Do you drink soda?

Question07/05/20 10:58 PM CDT

Yeah, I drink diet Coke.

How many glasses of water do you take daily?

Question07/05/20 10:59 PM CDT

Probably… 6 or 8 glasses? I drink a lot of water.

Have you had food poisoning?

Question07/05/20 10:59 PM CDT

I’ve had food poisoning when I was a kid, and this isn’t anything like that.

Have you had recent travel?

Question07/05/20 11:00 PM CDT

No. I’ve been here in Shadowville working my butt off!

Do you use illicit drugs?

Question07/05/20 11:00 PM CDT

Well, I used to smoke pot. . . but I don’t do that anymore.

do you smoke cigarette

Question07/05/20 11:00 PM CDT

No, I’ve never smoked a cigarette in my life.

Great! Smoking and drugs are not good for you

Educate07/05/20 11:01 PM CDT

OK, I understand.

are you bloated?

Question07/05/20 11:01 PM CDT

No, I don’t feel bloated.

Do you have sore throat?

Question07/05/20 11:02 PM CDT

No, my throat doesn’t hurt.

Are you coughing?

Question07/05/20 11:02 PM CDT

No, I haven’t been coughing.

do you have difficulty breathing?

Question07/05/20 11:02 PM CDT

No, my breathing has been fine.

do you have chest pain?

Question07/05/20 11:02 PM CDT

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?

Question07/05/20 11:03 PM CDT

No, I can taste everything fine.

Any family history of colon cancer?

Question07/05/20 11:03 PM CDT

Um, Grandpa Jones died of colon cancer.

am sorry to hear that

Empathize07/05/20 11:05 PM CDT

Thanks.

do you have a family history of GERD?

Question07/05/20 11:05 PM CDT

No.

Do you have a family history of ibs?

Question07/05/20 11:06 PM CDT

No, I haven’t heard anything about that.

Do you have a family history of Cholecystitis?

Question07/05/20 11:06 PM CDT

Not that I’ve heard of.

Any family history of liver disease?

Question07/05/20 11:06 PM CDT

No, nobody’s had anything happen with their liver that I know of.

Any family history of bladder disease?

Question07/05/20 11:07 PM CDT

Not that I’ve heard of.

Any family history of kidney disease?

Question07/05/20 11:10 PM CDT

No, nobody’s had that.

What are your allergies?

Question07/05/20 11:10 PM CDT

I’m allergic to cats.

what happens when you are around cats?

Question07/05/20 11:11 PM CDT

Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.

Are you allergic to dust?

Question07/05/20 11:11 PM CDT

Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.

are you allergic to penicillin?

Question07/05/20 11:12 PM CDT

Yes.

what do you take for asthma?

Question07/05/20 11:13 PM CDT

I have my Proventil inhaler, and then my daily Flovent inhaler, too.

what is the dosage of the proventil?

Question07/05/20 11:13 PM CDT

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.)

Question07/05/20 11:14 PM CDT

how consistent are your bowel movements? (Clarified to How often do you have a bowel movement?.)

Question07/05/20 11:15 PM CDT

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?

Question07/05/20 11:16 PM CDT

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

how many meals do you typically eat in a day?

Question07/05/20 11:17 PM CDT

I try to eat breakfast, lunch, and dinner. I usually have a snack somewhere in there.

what did you have for dinner last night?

Question07/05/20 11:17 PM CDT

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

ok. such a heavy meal may upset your stomach

Educate07/05/20 11:18 PM CDT

Sure, I think I understand what you mean.

when did you last drink alcohol?

Question07/05/20 11:19 PM CDT

At least 2 weeks ago. I have been staying at from it.

do you smoke pot?

Question07/05/20 11:19 PM CDT

No, not since… not in like 6 or 7 years.

its good that you quit

Educate07/05/20 11:20 PM CDT

That makes sense.

Any fever?

Question07/05/20 11:20 PM CDT

No. No fever.

Any chills?

Question07/05/20 11:20 PM CDT

No, no chills.

Any fatigue?

Question07/05/20 11:20 PM CDT

No, I don’t feel tired.

any night sweats?

Question07/05/20 11:20 PM CDT

No.

do you have anxiety?

Question07/05/20 11:20 PM CDT

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

Empathize07/05/20 11:21 PM CDT

I appreciate you telling me that.

any feelings of stress?

Question07/05/20 11:21 PM CDT

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?

Question07/05/20 11:21 PM CDT

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

Educate07/05/20 11:22 PM CDT

Thanks for telling me.

Any nausea?

Question07/05/20 11:22 PM CDT

No, I’m fine.

Any vomiting?

Question07/05/20 11:22 PM CDT

No.

Any constipation?

Question07/05/20 11:23 PM CDT

I don’t have that problem.

any medications that you use?

Question07/05/20 11:24 PM CDT

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

what is your highest level of education?

Question07/05/20 11:24 PM CDT

Well, I’m finishing up my Bachelor’s degree right now.

what course are you pursuing? (No matching questions found.)

Question07/05/20 11:24 PM CDT

what is your major?

Question07/05/20 11:25 PM CDT

I’m going to get my bachelor’s in accounting.

Are you working?

Question07/05/20 11:25 PM CDT

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?.)

Question07/05/20 11:25 PM CDT

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?

Question07/05/20 11:26 PM CDT

Right now I live back at home with my mom and my sister.

Tested skin turgor on forearm

Exam Action07/05/20 11:27 PM CDT

Inspected right side of abdomen

Exam Action07/05/20 11:29 PM CDT

Inspected front of abdomen

Exam Action07/05/20 11:29 PM CDT

Inspected left side of abdomen

Exam Action07/05/20 11:29 PM CDT

Auscultated breath sounds in anterior right middle lobe