pdf (14).pdf - Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health Gastrointestinal Physical Assessment Assignment Results |

pdf (14).pdf - Gastrointestinal Physical Assessment...

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12/10/2018Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health1/4Gastrointestinal Physical Assessment Assignment Results | Turned InAdvanced Health Assessment - Chamberlain, NR509-October-2018Return to AssignmentYour ResultsLab PassLab PassDocument: Provider NotesDocument: Provider NotesStudent DocumentationStudent DocumentationModel DocumentationModel DocumentationSubjectivePatient info: Tina Jones, 28, African-AmericanFemale CC: frequent stomach pain HPI: Onset: Pain has been happening for "at least amonth" and getting worse with time, Location: Upper stomach, "under the breastbone".Does not radiate. Duration: Pain occurs everyday with 3 to 4 episodesa week that are worse. Pain starts 10 to 15 minutesafter eating and lasts "a few hours". Characteristics: Pain at the worst is "6 or 7" out of10. Pain is similar to heartburn. Aggravating Factors: Eating, especially larger mealsor spicy foods. Pain is worse when lying down orbending over. Relieving Factors: Time between meals, sittingupright Treatment: OTC Antacids (Tums) Current Medications: OTC Tums to relieve stomachpain. Reports that she takes between 2 to 4 "everyfew days". Patient is not taking any other newmedications other than her inhalers and OTC painHPI: Ms. Jones is a pleasant 28-year-old AfricanAmerican woman who presented to the clinic withcomplaints of upper stomach pain after eating. Shenoticed the pain about a month ago. She states thatshe experiences pain daily, but notes it to be worse3-4 times per week. Pain is a 5/10 and is located inher upper stomach. She describes it “kind of likeheartburn” but states that it can be sharper. Shenotes it to increase with consumption of food andspecifically fast food and spicy food make painworse. She does notice that she has increasedburping after meals. She states that time generallymakes the pain better, but notes that she does treatthe pain “every few days” with an over the counterantacid with some relief. Social History: She denies any specific changes inher diet recently, but notes that she has increasedher water intake. Breakfast is usually a muffin orpumpkin bread, lunch is a sandwich with chips,dinner is a homemade meal of a meat andvegetable, snacks are French fries or pretzels. Shedenies coffee intake, but does drink diet cola on aregular basis. She denies use of tobacco and illicitdrugs. She drinks alcohol occasionally, last was 2weeks ago, and was 1 drink. She does not exercise. Review of Systems: General: Denies changes inweight and general fatigue. She denies fevers, chills,and night sweats. • Cardiac: Denies a diagnosis ofhypertension, but states that she has been told herblood pressure was high in the past. She deniesknown history of murmurs, dyspnea on exertion,OverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationLifespanReview QuestionsSelf-ReflectionDocumentation / Electronic Health Record
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