Shadow Health Gastrointestinal SOAP Note Assignment

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

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Transcript

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

Gree 04/08/20 5:29 PM MD

Question 04/08/20 5:29 PM MD

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Empathize 04/08/20 5:29 PM MD

Educate 04/08/20 5:29 PM MD

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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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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

Shadow Health Gastrointestinal SOAP Note Assignment

 

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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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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

 

Shadow Health Gastrointestinal SOAP Note Assignment

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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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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

ORDER NOW FOR CUSTOMIZED SOLUTION PAPERS

Shadow Health Gastrointestinal SOAP Note Assignment

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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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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

 

Shadow Health Gastrointestinal SOAP Note Assignment

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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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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

 

Shadow Health Gastrointestinal SOAP Note Assignment

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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.Shadow Health Gastrointestinal SOAP Note Assignment

I’m going to listen to your femoral artery

OK, I understand.

Auscultated right femoral artery

ORDER NOW FOR CUSTOMIZED SOLUTION PAPERS

 

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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.Shadow Health Gastrointestinal SOAP Note Assignment

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.Shadow Health Gastrointestinal SOAP Note Assignment

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

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Shadow Health Gastrointestinal SOAP Note Assignment