Bowel movements are daily and generally brown in color Denies any change in

Bowel movements are daily and generally brown in

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nausea, vomiting, diarrhea, and constipation. Bowel movements are  daily and generally brown in color. Denies any change in stool color,  consistency, or frequency. Denies blood in stool, dark stools, or  maroon stools. No blood in emesis. No known jaundice, problems  with liver or spleen.
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Student Documentation Model Documentation or bloating. Bowels move normally every 2 days. Patient reports  normal stools, no blood or mucus. Denies any known issues of  gallbladder or gastrointestinal disorders. Family history of Colon  Cancer of paternal grandfather. GU- increased urination, color is  yellow to clear. Denies pain with urination. GYN- LMP one month ago HEMA- Denies bruising. Neuro- denies numbness or tingling. Reports headaches with studying. Musculoskeletal- denies muscle weakness,  denies joint or bone pain. Endocrine- reports diabetes diagnosed at  age 24. Psych- confirms increased level of stress Objective Mrs. Jones is an obese 28 year old African American female appears  in no acute distress sitting upright on exam table. Well-groomed, alert and oriented, maintains eye contact throughout interview. Answers  questions appropriately, good historian. Vitals: BP 138/80 HR 80 RR  15 Temp 99.6 SpO2 98% Room Air Weight 85kg BMI 29.4 BG 131  HEENT: head is normocephalic, midline and symmetrical. SKIN: good turgor no tenting noted. Striae and excessive hair growth noted on  abdomen. noted discoloration to neck -Acanthosis Nigricans. CV:  audible S1 S2, regular rate and rhythm. No extra heart sounds, no  murmurs, Gallop, clicks, S3, S4 noted. RESP: chest symmetrical,  breath sounds clear throughout no adventitious sounds/ No  wheezing, crackling rales, rubs, stridor, rhonchi. GI: Abd is  symmetrical, protuberant. bowel sounds normal active in all  quadrants, no bruits auscultated over abdominal aorta, renal arteries,  iliac arteries, femoral arteries. Percussed all four quadrants generally  tympanic throughout, tympany over spleen, percussed liver span at  7cm in the mid clavicular line, did not react when CV ] General: Ms. Jones is a pleasant, obese 28-year-old African  American woman in no acute distress. She is alert and oriented. She  maintains eye contact throughout interview and examination. •  Abdominal: Abdomen is soft and protuberant without scars or skin  lesions; skin is warm and dry, without tenting. Bowel sounds present  and normoactive in all quadrants. No tenderness to light or deep  palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm  below the right costal margin. Spleen and bilateral kidneys are not  palpable. No CVA tenderness. • Cardiovascular: Regular rate and  rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks,  precordial movements. No bruits with auscultation over abdominal 
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