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