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
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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
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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,
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