NRSE 5010 Advanced Health Assessment Gastrointestinal Completed Shadow Health

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NRSE 5010 Advanced Health Assessment Gastrointestinal Completed Shadow Health 3/18/2021 Gastrointestinal | Completed | Shadow Health 1/4 Gastrointestinal Results | Turned In Advanced Health Asse... ssment - Spring 2021, NRSE 5010 Return to Assignment (/assignments/427605/) Your Results Lab Pass (/assignment_attempts/9255508/lab_pass.p Overview Transcript Subjective Data Collection: 31 of 31 (100.0%) Subjective Data Collection Objective Data Collection Education & Empathy Documentation Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yiel better patient data. The following details are facts of t patient's case. Chief Complaint Established chief complaint Reports frequently occurring stomach pain History of Present Illness Asked about onset of pain Reports noticing pain for "at least a month" Reports that pain increased gradually Asked about frequency of pain Reports pain occurs every day Reports 3 to 4 episodes a week that are more severe Asked about duration of pain Pain begins right after finishing a meal Each episode lasts "a few hours" Asked about severity of pain on a scale Rates present pain as 1 or 2 out of 10 Rates worst pain after eating as 5 out of 10 Rates pain when supine as a 6 or 7 out of 10 Asked about character of the pain Describes the pain as similar to heartburn Denies crushing pain Denies gnawing pain Denies cramping pain Denies that abdomen is tender to the touch Asked location of the pain This study source was downloaded by 100000827528247 from CourseHero.com on 06-08-2021 15:10:02 GMT -05:00 Support3/18/2021 Gastrointestinal | Completed | Shadow Health 2/4 Pain is in center of upper stomach, below breastbone Pain does not radiate Denies shoulder pain Denies back pain Denies arm pain Denies flank pain Denies pain on right side of abdomen Asked about aggravating factors Pain occurs after eating Pain worsens with larger meals Reports that spicy foods increase the pain Denies high-fat foods as an aggravating factor Pain worsens when supine Pain worsens when bending over Asked about relieving factors Pain improves between meals Pain improves when upright Asked about effects of pain on diet and appetite Reports decreased appetite Describes not wanting to eat out of anticipation of pain Reports eating smaller meals Reports avoiding spicy foods Asked about increased burping Reports burping Burping occurs after eating Medical History Asked about changes in weight Denies recent weight loss Confirmed use of medications Confirms medications (no new medications reported) Reports occasional antacid use Denies frequent Advil (ibuprofen) use Followed up on use of antacids and relieving factors Antacid brand is Tums Takes antacids every few days Takes between 2 and 4 antacid tablets at a time Reports that antacids offer partial relief3/18/2021 Gastrointestinal | Completed | Shadow Health 3/4 Confirmed allergies Confirms allergies (no new allergies reported) Asked about past gastrointestinal history Denies past history of ulcers Denies gastrointestinal disease Denies past history of GERD Denies past gastrointestinal surgery Denies past history of appendicitis Denies past history of cholecystitis Denies past history of stomach cancer Denies past history of liver disease Denies past history of kidney disease Denies past history of bladder disease Asked about typical bowel movements Reports bowel movement every 2 days Denies pain during bowel movements Denies bloody or tarry stools Denies mucus in stool Describes consistency of bowel movements Asked about typical urination Reports increased urination Reports urine is a clear or light-yellow color Reports nocturia Denies pain during urination Describes urine character as normal Denies pink or bloody urine Denies incontinence Asked about menstruation and sexual activity LMP was 3 weeks ago Denies sexual activity Social History Asked about most recent meal Most recent meal was breakfast this morning Most recent meal was toast with butter and honey and orange juice Asked 24-hour diet recall Yesterday's breakfast was cereal Yesterday's lunch was pizza Yesterday's dinner was a baked potato Asked about typical diet Reports typical intake is 3 meals a day plus snacks Typical breakfast is cereal, bread, or a muffin Typical lunch is a sandwich and chips Typical dinner is chicken, a vegetable or potatoes, and bread Reports fast food intake 3 times a week Typical snack is pretzels, French fries, crackers or chips Asked about typical beverages Last alcoholic drink was 2 weeks ago Typical alcohol frequency is 2 - 3 times a month Typical alcohol intake is 2 - 3 drinks at a time Reports that alcohol intake bothered her stomach Reports drinking soda Reports drinking 3 - 4 diet cokes a day3/18/2021 Gastrointestinal | Completed | Shadow Health 4/4 Reports that she hasn't noticed a connection between soda intake and pain Reports drinking 6 - 8 glasses of water a day Asked about recent dietary and life experiences Denies recent travel Denies food poisoning Asked about substance use Denies illicit drug use Denies cigarette smoking Social Determinants of Health3/18/2021 Gastrointestinal | Completed | Shadow Health 5/4 Comments If your instructor provides individual feedback on this assignment, it will appear here. Asked about food access Reports living near grocery store Reports access to fresh foods Review of Systems Asked about general symptoms Denies fever Denies chills Denies fatigue Denies night sweats Asked about review of systems for mental health Reports occasional feelings of anxiety Reports feelings of stress Asked about review of systems for gastrointestinal Denies nausea Denies vomiting Denies diarrhea Denies constipation Denies flatus Denies bloating [Show More]

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