12102018 Gastrointestinal Physical Assessment Assignment Completed Shadow

12102018 gastrointestinal physical assessment

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12/10/2018Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health3/4Student DocumentationStudent DocumentationModel DocumentationModel DocumentationObjectiveTina Jones was a pleasant, 28 year old AfricanAmerican female. She was obese, but in no signs ofvisual distress. She was alert and oriented. Shemaintained eye contact and answered questions fullyand correctly. She was dressed well and seemed tohave good hygiene. Abdominal: Visua; inspection found skin turgor hadno tenting. Abdomen was symmetric, protuberant,with striae and excessive hair growth around thebelly button. Bowel sounds in all quadrants werenormoactive. Patient did not react to CVApercussion. Spleen was tympanic. Liver wasbetween 6 and 12 cm. No abdominal tenderness. Nopalpable masses in the abdomen. Liver waspalpable. Spleen not palpable. Kidneys not palpable. Cardiovascular: S1 and S2 were audible with noextra sounds. Abdominal, Renal, Iliac, Femoralarteries all had no bruit. Respiratory: Symmetrical chest. Ausculatation foundclear breath sounds present in all areas with noadventitious sounds.General: Ms. Jones is a pleasant, obese 28-year-oldAfrican American woman in no acute distress. She isalert and oriented. She maintains eye contactthroughout interview and examination. • Abdominal: Abdomen is soft and protuberantwithout scars or skin lesions; skin is warm and dry,without tenting. Bowel sounds present andnormoactive in all quadrants. No tenderness to lightor deep palpation. Tympanic throughout. Liver is 7cm at the MCL and 1 cm below the right costalmargin. Spleen and bilateral kidneys are notpalpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 andS2 present, no murmurs, rubs, gallops, clicks,precordial movements. No bruits with auscultationover abdominal aorta. No femoral, iliac, or renalbruits. • Respiratory: Chest is symmetrical with respirations.Lung sounds clear to auscultation anteriorly andposteriorly without wheezes, crackles, or cough.Assessment1. Gastroesophageal reflux disease, or GERD: Thepatient matches most of the symptoms for GERD,like pain after eating and a heartburn like feeling. 2. Peptic Ulcer Disease: Peptic Ulcer Disease, orulcers, in general, can cause lots of pain after eating.She does not have nausea, however, a commonsymptom. 3. Achalasia: This can cause pain after eating, but itis typically due to dysphagia, or difficulty swallowing.This was not a symptom that Tina talked about, so Ibelieve that this is a less likely diagnosis.Gastroesophageal reflux disease without evidenceof esophagitis
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12/10/2018Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health4/4Student DocumentationStudent DocumentationModel DocumentationModel DocumentationPlanDiagnostics: I would like to order an upper endoscopy for Tina tolook for any issues with the esophagus or thestomach and to rule out any ulcers to confirm adiagnosis of GERD.
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  • Fall '15
  • Gastroesophageal reflux disease

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