509 Gastrointestinal Documentation

509 gastrointestinal documentation

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12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health 3/4 Student Documentation Student Documentation Model Documentation Model Documentation Objective Tina Jones was a pleasant, 28 year old African American female. She was obese, but in no signs of visual distress. She was alert and oriented. She maintained eye contact and answered questions fully and correctly. She was dressed well and seemed to have good hygiene. Abdominal: Visua; inspection found skin turgor had no tenting. Abdomen was symmetric, protuberant, with striae and excessive hair growth around the belly button. Bowel sounds in all quadrants were normoactive. Patient did not react to CVA percussion. Spleen was tympanic. Liver was between 6 and 12 cm. No abdominal tenderness. No palpable masses in the abdomen. Liver was palpable. Spleen not palpable. Kidneys not palpable. Cardiovascular: S1 and S2 were audible with no extra sounds. Abdominal, Renal, Iliac, Femoral arteries all had no bruit. Respiratory: Symmetrical chest. Ausculatation found clear breath sounds present in all areas with no adventitious sounds. 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 aorta. No femoral, iliac, or renal bruits. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. Assessment 1. Gastroesophageal reflux disease, or GERD: The patient matches most of the symptoms for GERD, like pain after eating and a heartburn like feeling. 2. Peptic Ulcer Disease: Peptic Ulcer Disease, or ulcers, in general, can cause lots of pain after eating. She does not have nausea, however, a common symptom. 3. Achalasia: This can cause pain after eating, but it is typically due to dysphagia, or difficulty swallowing. This was not a symptom that Tina talked about, so I believe that this is a less likely diagnosis. Gastroesophageal reflux disease without evidence of esophagitis This study resource was shared via CourseHero.com
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12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health 4/4 Student Documentation Student Documentation Model Documentation Model Documentation Plan Diagnostics: I would like to order an upper endoscopy for Tina to
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  • Fall '15
  • Gastroesophageal reflux disease

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