Tina Jones Gastrointestinal Documentation

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

Documentation / Electronic Health Record

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

 https://w....................................../file35179 7m/NeRd

-

ic

5a

0t

9i

-

oGn

as

sto

r

t

oh

ine

t

r

es

th

tia

nn

al-hDe

or

ci

unmha

enle

tars

tioa

nn

-

d

ShOadToCwp

pda

f

i

/n

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Lifespan

Review Questions

Self-Reflection

 1 / 2

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

https://chamberlain.shadowhealth.com/assignment_attempts/4249614 2/4

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,

Powered by qwivy(www.qwivy.org)

 2 / 2

No comments found.
Login to post a comment
This item has not received any review yet.
Login to review this item
No Questions / Answers added yet.
Version 2021
Category Case Study
Included files pdf
Pages 4
Language English
Comments 0
Sales 0
Recently viewed items

We use cookies to understand how you use our website and to improve your experience. This includes personalizing content and advertising. To learn more, please click Here. By continuing to use our website, you accept our use of cookies, Privacy policy and terms & conditions.

Processing