Dictation Practice – Part A07
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Audio
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Answer
- stomach pain
- nine/9
- generalized
- morning
- five/5
- medical
- primrose (tablet)
- bladder
- punches
- okay/ok/normal
- blockage
- appendicitis
Transcript
Dr. Hudson: | Hello, Mrs Hanson. I’m Dr.Hudson. I understand you’re having some pain. |
Mrs.Hanson | Oh, Yes. I have stomach pain. |
Dr. Hudson: | When did it start? |
Mrs.Hanson | Last night. |
Dr. Hudson: | Last night. About what time? |
Mrs.Hanson | Nine |
Dr. Hudson: | Nine. Where was it when it first started? |
Mrs.Hanson | It was kind of generalized. |
Dr. Hudson: | All around? |
Mrs.Hanson | Yes. |
Dr. Hudson: | Okay. Did it change at all? |
Mrs.Hanson | Yeah. |
Dr. Hudson: | (Where…) How did it change? |
Mrs.Hanson | Now this morning when I woke up, it was more central and now it’s more here. |
Dr. Hudson: | On the right side. |
Mrs.Hanson | Yes. |
Dr. Hudson: | What kind of pain is it? |
Mrs.Hanson | It’s right there. (Okay.) And it’s constant. |
Dr. Hudson: | It’s constant. Is it like a grabbing pain, a stabbing pain, or a dull ache? |
Mrs.Hanson | A dull ache. |
Dr. Hudson: | A dull ache. Is it going around the back at all? (No.) Down in the groin area? (No) It’s just right there now? (Yes) but it started more generalized.
On a scale of 1 to 10 last night, how bad was the pain? |
Mrs.Hanson | I would say, two. |
Dr. Hudson: | Two. And now what would you say? |
Mrs.Hanson | Seven. |
Dr. Hudson: | Seven. Okay.
When it first started, were you doing anything in particular? Did you lift something heavy? (No) Did you twist? Was there any trauma? |
Mrs.Hanson | I was just looking at the TV. |
Dr. Hudson: | Okay. All right. Through the night, did it wake you up? |
Mrs.Hanson | No. I slept. |
Dr. Hudson: | You were able to sleep. Okay. Do you feel nauseated? |
Mrs.Hanson | This morning. |
Dr. Hudson: | This morning. Did you throw up? |
Mrs.Hanson | Yeah. |
Dr. Hudson: | And how’s your appetite? Do you feel hungry? Do you want to eat? |
Mrs.Hanson | Oh, no. |
Dr. Hudson: | You don’t. Okay. Did you have any fever? |
Mrs.Hanson | I did not take it but now I feel kind of feverish. |
Dr. Hudson: | You feel a bit feverish. Did you have any night sweats last night? |
Mrs.Hanson | No. |
Dr. Hudson: | Chills where you were shaking? |
Mrs.Hanson | No, but this morning it started. |
Dr. Hudson: | Okay. Tell me about your bowel movements. When was the last one? |
Mrs.Hanson | Yesterday morning. |
Dr. Hudson: | Okay. Was it normal? |
Mrs.Hanson | Yes. |
Dr. Hudson: | Did you have a period of time in the last week or so? Or were you either constipated or had diarrhea? |
Mrs.Hanson | No. |
Dr. Hudson: | Have you recently noticed any blood in your stools (No) Or any black diarrhea stool? |
Mrs.Hanson | No. |
Dr. Hudson: | Are you having problems with your bladder in terms of burning to urinate? Having to get up at night to urinate? |
Mrs.Hanson | No. |
Dr. Hudson: | Have you seen any blood in your urine? |
Mrs.Hanson | No. |
Dr. Hudson: | Okay. Tell me about your period. So do you still menstruate? |
Mrs.Hanson | No, no, no. It stopped five years ago. |
Dr. Hudson: | Five years ago. Okay. Alright. And you haven’t had any spotting bleeding at all? |
Mrs.Hanson | No. |
Dr. Hudson: | And are you sexually active? |
Mrs.Hanson | Not for the last six months. |
Dr. Hudson: | (Last…) No new partners for the last six months. Okay.
Have you ever had any problems with this kind of pain before? (No) Similar pain? (No) This is the first time. Tell me about your health. Do you have any other medical problems? |
Mrs.Hanson | No. |
Dr. Hudson: | High blood pressure, cholesterol problems, heart problems? |
Mrs.Hanson | No. |
Dr. Hudson: | Do you take medications? |
Mrs.Hanson | Just only a homeopathic one. |
Dr. Hudson: | Okay. Which ones are those? |
Mrs.Hanson | Primrose. I’m sorry. I take selenium, and I take vitamin C and A, and primrose tablets |
Dr. Hudson: | Primrose tablets. Okay. Do you take any aspirin at all? |
Mrs.Hanson | No. |
Dr. Hudson: | Any ibuprofen? |
Mrs.Hanson | No. |
Dr. Hudson: | Okay. Do you have allergies to medications? |
Mrs.Hanson | No. |
Dr. Hudson: | Have you ever had surgery before? |
Mrs.Hanson | No. |
Dr. Hudson: | So you don’t know if you have any issues regarding general anesthetic (No) , problems like that?
Family history in particular of bleeding tendencies or blood clot problems? |
Mrs.Hanson | No. |
Dr. Hudson: | Okay. Have you ever had kidney infections and bladder infections? |
Mrs.Hanson | No. Never. |
Dr. Hudson: | Alright.
So I’m going to examine you. Okay. So if you want to bring your legs down here, just bring them down gently. I know it’s gonna hurt a little bit. Okay. And now I’m going to just have a look at your abdomen. Okay. So we’re going to just expose here. And I’m gonna look to see if your abdomen is distended. (Do) you feel bloated at all with your belly all swollen up? Okay. So it looks good, I don’t see any swelling of your abdomen or any bulging anywhere. So, now I’m going to um give little taps. Okay. So show me the area where you are sore. |
Mrs.Hanson | Here. |
Dr. Hudson: | Here, okay. So we’re gonna save that spot for last. So I’m just gonna give little punches here. That hurts you a bit. Okay.
Now, I’m just going to lightly palpate just on the top like that. That’s all Okay. How about down here? That hurts a bit. Okay. Now, I’m gonna go deeper down. Okay. That’s okay there? And if I press here, do you feel a little bit. And where do you feel that when I’m pressing here? So you feel it on that side. Okay. Now I’m gonna go deeper here. Okay. So I do see that your muscles are tensing up when I’m doing that. Okay. I’m gonna do another test where I’m going to press down and I’m gonna let go. Okay. So you tell me if it hurts, So I’m gonna press down, I know it hurts here. I’m gonna let go. Okay. That does hurt. And I’m going to do it on this side too. I’m gonna press down. Okay. I’m gonna let go. That really hurts. Okay. Sorry about that. And I’m gonna listen for your bowel sounds. Okay. And I should have done this before palpitating you, but let me have a listen here. Okay. So I’m just gonna listen in all four quadrants in all areas of the abdomen. Very good. So your bowel sounds are okay? So we see that the gasses is going through so that there’s no blockage there. Okay. So now I’m gonna ask you to lift up your leg. Okay. And keep it up. So, well let’s bring your leg out of the blanket. We will make it easier for you. Just bring it up in the air like that and just don’t let me push your leg down. You tell me if it hurts. That does hurt. Okay. Alright. So let’s bring this down. Okay. And now I’m just going to be pressing a little bit on your kidneys back here. Does that hurt you? (No) Okay. And how about on this side does that hurt you? And that’s good. Very good. Now I’m gonna want to have a little bit of an examination to look at your tubes and your ovaries. We call a gynecological examination. |
Gynecologist: | Is the Exam is normal? |
Dr. Hudson: | Very good. And another thing that we need to do is do a rectal examination and that’s to put a finger in and feel the area where… |
Gynecologist: | That examination is normal? |
Dr. Hudson: | It is normal. Okay. Very good. So that concludes… |
Gynecologist: | I have a question for you. What’s your diagnosis? |
Dr. Hudson: | Well, my principal diagnosis is appendicitis at this point. |