12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health

https://chamberlain.shadowhealth.com/assignment_attempts/4249614 1/4

Gastrointestinal Physical Assessment Assignment Results | Turned In

Advanced Health Assessment - Chamberlain, NR509-October-2018

Return to Assignment

Your Results Lab Pass

Document: Provider Notes

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Patient info: Tina Jones, 28, African-American

Female

CC: frequent stomach pain

HPI:

Onset: Pain has been happening for "at least a

month" and getting worse with time,

Location: Upper stomach, "under the breastbone".

Does not radiate.

Duration: Pain occurs everyday with 3 to 4 episodes

a week that are worse. Pain starts 10 to 15 minutes

after eating and lasts "a few hours".

Characteristics: Pain at the worst is "6 or 7" out of

10. Pain is similar to heartburn.

Aggravating Factors: Eating, especially larger meals

or spicy foods. Pain is worse when lying down or

bending over.

Relieving Factors: Time between meals, sitting

upright

Treatment: OTC Antacids (Tums)

Current Medications: OTC Tums to relieve stomach

pain. Reports that she takes between 2 to 4 "every

few days". Patient is not taking any other new

medications other than her inhalers and OTC pain

HPI: Ms. Jones is a pleasant 28-year-old African

American woman who presented to the clinic with

complaints of upper stomach pain after eating. She

noticed the pain about a month ago. She states that

she experiences pain daily, but notes it to be worse

3-4 times per week. Pain is a 5/10 and is located in

her upper stomach. She describes it “kind of like

heartburn” but states that it can be sharper. She

notes it to increase with consumption of food and

specifically fast food and spicy food make pain

worse. She does notice that she has increased

burping after meals. She states that time generally

makes the pain better, but notes that she does treat

the pain “every few days” with an over the counter

antacid with some relief.

Social History: She denies any specific changes in

her diet recently, but notes that she has increased

her water intake. Breakfast is usually a muffin or

pumpkin bread, lunch is a sandwich with chips,

dinner is a homemade meal of a meat and

vegetable, snacks are French fries or pretzels. She

denies coffee intake, but does drink diet cola on a

regular basis. She denies use of tobacco and illicit

drugs. She drinks alcohol occasionally, last was 2

weeks ago, and was 1 drink. She does not exercise.

Review of Systems: General: Denies changes in

weight and general fatigue. She denies fevers, chills,

and night sweats. • Cardiac: Denies a diagnosis of

hypertension, but states that she has been told her

blood pressure was high in the past. She denies

known history of murmurs, dyspnea on exertion,

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Lifespan

Review Questions

Self-Reflection

Documentation / Electronic Health Record

https://www.qwivy.com/file/36351797/NR-509-Gastrointestinal-Documentation-Shadowpdf/

This study resource was

shared via qwivy.com

Powered by qwivy(www.qwivy.org)

 1 / 1