12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
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Gastrointestinal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
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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/
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Category | Exam (elaborations) |
Pages | 4 |
Language | English |
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