GI A4: Shadow Health

Shadow Health

Professional Development

• Write a 500-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
  • What went well in your assessment?
  • What did not go so well? What will you change for your next assessment?
  • What findings did you uncover?
  • What questions yielded the most information? Why do you think these were effective?
  • What diagnostic tests would you order based on your findings?
  • What differential diagnoses are you currently considering?
  • What patient teaching were you able to complete? What additional patient teaching is needed?
  • Would you prescribe any medications at this point? Why or why not? If so, what?
  • How did your assessment demonstrate sound critical thinking and clinical decision making?

Gastrointestinal Results | Completed Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313476/)

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Transcript

Started: Apr 08, 2020 | Total Time: 48 min

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Your Results Lab Pass (/assignment_attempts/6541639/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Interview Questions (104) Statements (26) Exam Actions (52)

Hello Miss Jones my name is Doris and I’m here to see you again

Hey.

Maya just verify your name and date of birth (Clarified to What is your name and birthday?.)

My name’s Tina Jones, and my birthday’s February 17th. (Clarified to what is my name and date of birth.)

What brings you in today

I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me.

I’m sorry that must be hard for you

I appreciate you saying that.

Let’s see what we can figure out here as I go to your history

Sure, I think I understand what you mean.

Me ask when did the pain start

Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad.

Is it getting worse

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

Can I ask how often are you having the pain

It’s every time I eat.

How many episodes in a day (No matching questions found.)

IS THAT 3 TIMES A DAY (No matching questions found.)

Does this happen every day (No matching questions found.)

Is it pain daily

Yeah, I notice it every day. It seems like… 3 or 4 times a week, I’ll have an episode that’s worse.

How long does it pain last

For a few hours after I eat.

What makes it worse

Eating seems to cause it.

What makes it better

Talking to friends or family and going to church always help me feel less stressed–just feeling supported and like someone cares.

How strong is your pain from 1 to 10 (Clarified to How severe is your pain?.)

Right now, I don’t really notice anything, but it can get bad after I eat. (Clarified to how severe my pain is.)

From 1 to 10 10 being the worst what is it (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)

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.)

Does it help when you’re sitting up (Clarified to Does the pain improve when you sit up?.)

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

Can you describe the pain

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

Do you have chest pain

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.

Does it feel cramping

No, it’s not like stomach cramps.

Does it hurt to touch your belly

Yes. Every time I eat it hurts. I’ve been eating less because I don’t like being in pain.

Have you lost weight

No, I don’t think so.

Where’s the location of the pain

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

Does it radiate to your back (No matching questions found.)

Does it radiate to your SHOULDER (No matching questions found.)

Does it radiate to your back (No matching questions found.)

DOES THE PAIN RADIATE TO YOUR ARM

No, it’s right in the center of my stomach, like between my belly button and my ribs.

Let’s review your diet

Thanks for telling me.

May I ask what food do you eat (No matching questions found.)

Give me a diary of your food intake (No matching questions found.)

Does the pain get worse with large meals (Clarified to Do large meals make the pain worse?.)

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Yes, large meals make the pain worse. [AUDIO COMING SOON] (Clarified to if large meals make the pain worse.)

Do you eat spicy food

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 fried foods

Not too much. I mean, I like French fries and stuff, but I try not to eat them too often.

How’s your appetite

I haven’t been wanting to eat lately.

Why don’t you want to eat

It seems like if I eat too much, that’s what makes my stomach pain the worst.

Do you have any burping

Yeah, that’s been happening after I eat.

What food are you eating

I don’t have any food allergies that I know of.

What medication are you taking right now

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

Are you taking any over-the-counter medication

I’ve been taking antacids lately — chewable ones.

Does it help (Clarified to Does taking the antacids help?.)

Yeah, they help. I try to only take them when the pain seems worse than usual. (Clarified to if the antacids help.)

How often are you taking antacids

I take them every few days. Just if the heartburn gets bad.

Are you taking any ibuprofen

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Yeah, I still take it for cramps.

How often are you taking that (Clarified to How often do you take over the counter medication?.)

I take them every few days. Just if the heartburn gets bad. (Clarified to how often I take over the counter medication.)

Do you have drug allergies

Yeah, I’m allergic to penicillin.

What happens with Penicillin

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

I’m glad you know that you’re allergic to penicillin

Alright, thanks for letting me know.

Do you have any gastrointestinal problems

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

Have you had ulcers

No.

Have you had any GERD

I’m not really sure what GERD is. I’ve never been diagnosed with it, or anything. [AUDIO COMING SOON]

Have you had any GI surgery

No.

Have you had any appendicitis

No.

Have you had any problems with your gallbladder

No, as far as I know my gallbladder’s never had any problems.

That’s good to hear

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OK, I understand.

Have you had any stomach cancer (Clarified to Have you had stomach cancer?.)

No. (Clarified to if I have had stomach cancer.)

Do you have family history of stomach cancer

The only cancer that I know of in our family is colon cancer–Grandpa Jones died of that.

Have you any problems with your bladder

No, I never have.

How often do you have a bowel movement

Usually every other day.

Is your stool bloody

Um, no.

Do you have mucus in your stool

Ew. No.

What is the consistency of your stool (Clarified to Can you describe your stool?.)

Uh… usually light or dark brown, I guess? (Clarified to what my stool looks like.)

Do you have trouble peeing

No, I can pee fine.

Do you pee frequently

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

Do you have painful urination

No.

Is your urine clear

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

Do you have accidentally pee on yourself (Clarified to Have you ever peed yourself?.)

Definitely not. (Clarified to if I have ever had urinary incontinence.)

When was your last menstrual period

I think it was just about a month ago.

Are you sexually active

Um, not right now.

Can you tell me what you have for breakfast (Clarified to What did you eat for breakfast today?.)

This morning, I had toast with butter and honey, and some orange juice. (Clarified to what I ate for breakfast today.)

Can you tell me your diet within the 24 hour period (Clarified to What do you eat in an average day?.)

Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to what I typically eat in a day.)

What did you have for lunch yesterday

I had a piece of pizza. It was someone’s birthday at work, so they ordered pizza for all of us.

What did you have for dinner

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

Sounds like you have a lot of carbs in your diet maybe we should talk about that later

That makes sense.

Do you drink alcohol

Not lately, but I do every so often.

How often do you drink alcohol

Very rarely.

How many drinks in a setting

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Never any more than 2 or 3.

Do you drink soda

Yeah, I drink diet Coke.

How often (Clarified to How often do you drink a soda?.)

I have 3 or 4 diet cokes a day. (Clarified to how often I drink a soda.)

That’s a lot of Coke in a day and it has lots of acid which may cause your heartburn

OK, I understand.

Do you eat fast food

I probably have fast food a few times a week, usually when I’m on campus. Sometimes I don’t bring a lunch, and I get so starving I have to get something from one of the places around campus.

Do you drink caffeine

Like diet Cokes? Yeah, I drink them a lot.

Do you have a fever

No. No fever.

Do you have chills

No, no chills.

Do you smoke cigarette

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

Do you take illicit drugs

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

Do you feel fatigued

No, I don’t feel tired.

Do you get night sweats

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No.

Do you have any mental health issues

No, definitely not.

Anxiety

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.

Do you have nausea

No, I’m fine.

GI vomiting

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

Do you have diarrhea

No.

Are you gassy

No.

Do you have bloating

No, I don’t feel bloated.

Sore throat

No, my throat doesn’t hurt.

Any cough

No, I haven’t been coughing.

Any difficulty swallowing

No, I can swallow my food and everything.

Do you have difficulty breathing

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No, my breathing has been fine.

Do you have palpitation

No, not right now.

Has your sense of taste changed

No, I can taste everything fine.

Do you have a family history of GERD

No.

Any family history of irritable bowel syndrome

No, I haven’t heard anything about that.

Any family history of colon cancer

Um, Grandpa Jones died of colon cancer.

Anybody in your family with gallbladder disease

I don’t think so.

Any family history of liver disease

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

Any problems with kidney disease (Clarified to Does kidney disease run in your family?.)

No, nobody’s had that. (Clarified to if kidney disease runs in my family.)

Family history of bladder disease

Not that I’ve heard of.

Do you have any medical problems

Yeah. . . I have asthma and diabetes.

What do you take for your diabetes

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I don’t take medicine for it anymore.

What medication are you on for asthma

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

Is it helpful

My daily inhaler has helped a lot, yeah. I haven’t needed my rescue inhaler since I started it a few months ago.

And you mentioned no drug allergies

Sure, I think I understand what you mean.

It sounds like your diet had a lot of carbs which is not good for diabetes, but also that your food and liquids contain a lot of acid forming foods, and we should review that

Alright, thanks for letting me know.

We’re going to do our exam now

Thanks for telling me.

Do you exercise

I don’t have the energy to go to a gym or anything after work. . . I’m pretty exhausted by the end of the day. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least.

Tested skin turgor on forearm

Inspected right side of abdomen

Inspected front of abdomen

Inspected left side of abdomen

Inspected front of abdomen

Inspected right side of abdomen

I was looking at your stomach to see if there’s any rashes

That makes sense.

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I want to listen to breath sounds

Thanks for telling me.

Please breathe in and out when I move my stethoscope

OK, I understand.

Auscultated breath sounds in anterior right upper lobe

Auscultated breath sounds in anterior right middle lobe

Auscultated breath sounds in anterior right lower lobe

Auscultated breath sounds in anterior left upper lobe

Auscultated breath sounds in anterior left mid-chest (upper lobe)

Auscultated breath sounds in anterior left lower lobe

Listen to your heart now

Alright, thanks for letting me know.

Auscultated aortic area with the bell

Just stay relaxed

That makes sense.

Auscultated pulmonic area with the bell

Auscultated Erb’s point with the bell

Auscultated tricuspid area with the bell

Auscultated tricuspid area with the diaphragm

Auscultated mitral area with the diaphragm

Going to listen to your bowel sounds

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Sure, I think I understand what you mean.

Auscultated right upper quadrant

Auscultated right lower quadrant

Auscultated left lower quadrant

Auscultated left upper quadrant

Listen to your abdominal aorta

Alright, thanks for letting me know.

Auscultated aorta in abdomen

Great I don’t hear abnormal sounds

Thanks for telling me.

I’m going to listen to your arteries that goes to your kidneys

Sure, I think I understand what you mean.

Auscultated right renal artery

Auscultated left renal artery

Auscultated right iliac artery

Auscultated left iliac artery

I’m just listening to all the blood flow of the arteries

That makes sense.

I’m going to listen to your femoral artery

OK, I understand.

Auscultated right femoral artery

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Auscultated left femoral artery

I’m going to tap around your abdomen

Sure, I think I understand what you mean.

Percussed right upper quadrant

Percussed right lower quadrant

Percussed right upper quadrant

Percussed left upper quadrant

Percussed left lower quadrant

I’m going to tap on your back

OK, I understand.

Percussed left flank for CVA tenderness

Percussed left flank for CVA tenderness

Percussed right flank for CVA tenderness

I’m going to feel for your spleen

Alright, thanks for letting me know.

Percussed spleen

Percussed for liver span: 7 cm in the mid-clavicular line

I’m going to press lightly into your abdomen

That makes sense.

Percussed right lower quadrant

Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

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Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Palpated right lower quadrant: with deep pressure: No masses

Palpated right upper quadrant with deep pressure: No masses

Palpated left upper quadrant with deep pressure: No masses

Palpated left lower quadrant with deep pressure: No masses

I’m going to feel for your liver

Thanks for telling me.

Palpated liver: Palpable 1 cm below right costal margin

Palpated for spleen: Not palpable

Palpated for right kidney: Not palpable

Palpated for left kidney: Not palpable

Comments

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Gastrointestinal Results | Completed Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

this 28 you African pleasant female, presents with complaints of stomach pains that started a month ago. “feels like heartburn” Relieved with antacids, but is getting worse. Pain 1-2 right now, but a 5/10 after eating. Eating makes it worse. Sitting up helps. PMH: diabetes: no meds: Asthma: on proventil and albuterol: controlled Social hx: hx of THC use, none now. drinks 3-4 cans of soda in a day. ROS: heart burn normal form of stools, no diarrhea or constipation : Denies mental health issues: FMK PGF with colon cancer Diet: lots of fried and fast food: Exercise: limited

HPI: Ms. Jones is a pleasant 28-year-old African American woma who presented to the clinic with complaints of upper stomach pa after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3-4 time per week. Pain is a 5/10 and is located in her upper stomach. Sh describes it “kind of like heartburn” but states that it can be shar She notes it to increase with consumption of food and specifical fast food and spicy food make pain worse. She does notice that has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “ev few days” with an over the counter antacid with some relief. Social History: She denies any specific changes in her diet recen but notes that she has increased her water intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chip dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink cola on a regular basis. She denies use of tobacco and illicit drug She drinks alcohol occasionally, last was 2 weeks ago, and was drink. She does not exercise. Review of Systems: General: Denies changes in weight and gene fatigue. She denies fevers, chills, and night sweats. • Cardiac: De a diagnosis of hypertension, but states that she has been told he blood pressure was high in the past. She denies known history o murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturna dyspnea, or edema. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization wa age 16, last chest XR was age 16. • Gastrointestinal: States that general her appetite is unchanged, although she does note that s will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, a constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequenc Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen.

Your Results Lab Pass (/assignment_attempts/6541639/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Noteshttps://aspen.shadowhealth.com/assignments/313476/https://aspen.shadowhealth.com/assignment_attempts/6541639/lab_pass.pdf

Student Documentation Model Documentation

Objective

Skin Turgor : no tenting Lungs; CTA: Heart: Normal S1, S2 sounds. no murmur Abdominal : round, distended, discoloration, striae, no scars noted, symetrical. normal bowel sounds, no organomegly or rebound tenderness Liver palpable 1cm below right costal margin: Liver percussion with 7cm span in the mid-clavicular line. Spleen: not palpable: no tenderness Kidney: No CVA tenderness, not palpable

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination. • Abdominal: Abdomen is soft and protuberant without scars or s lesions; skin is warm and dry, without tenting. Bowel sounds pre and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 below the right costal margin. Spleen and bilateral kidneys are no palpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, n murmurs, rubs, gallops, clicks, precordial movements. No bruits auscultation over abdominal aorta. No femoral, iliac, or renal bru • Respiratory: Chest is symmetrical with respirations. Lung sound clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough.

Assessment

Heartburn Possible GERD

Gastroesophageal reflux disease without evidence of esophagitis

Plan

Discuss diet and avoiding fried, spicy, and soda foods. Exercise regimen encouraged Daily activy encouraged Take small frequent meals Consider Zantac if needed F/u in one week with above regimen. consider h-phyloric IGG/IGM if persistent sx Return to clinic if symptoms worsen, bloody stools RT hospital if chest pain

Educate on lifestyle changes including weight loss, engagement daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcoh and spicy foods. • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduc • Encourage to eat smaller meals and to avoid eating 2-3 hours before bedtime. • Educate on dietary reduction in fat to decrease symptoms. • Trial of ranitidine 150 mg by mouth daily for two we If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, consider testing for helicobacter pylori, trial o proton pump inhibitor, or upper endoscopy. • Educate on when t seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain. • Retur clinic in two weeks for evaluation and follow up.

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Gastrointestinal APA n518- 4.docx by Doris Untalan

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