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NR 509 Gastrointestinal Physical Assessment Assignment _ Documentation
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Gastrointestinal Physical Assessment Assignment Results | Turned InAdvanced Health Assessment - Chamberlain, NR509-October-2018
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Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Lifespan
Subjective
HPI: Ms. Jones is a pleasant 28-year-old African
Review Questions
CC: Abdominal pain American woman who presented to the clinic with
Onset: 1 month ago complaints of upper stomach pain after eating. She
Self-Reflection noticed the pain about a month ago. She states that
Location: mid-upper abdomen, below breast bone
(epigastric area) she experiences pain daily, but notes it to be worse
Duration: a few hours, occurs after eating 3-4 times per week. Pain is a 5/10 and is located in
Characteristics: "feels like heartburn", describes as a her upper stomach. She describes it “kind of like
burning feeling but sharper. Hurts a little after each heartburn” but states that it can be sharper. She
meal, 3-4 times a week it's bad. Currently pain 1- notes it to increase with consumption of food and
2/10, after eating pain is 5/10. Also has burping after specifically fast food and spicy food make pain
eating. Spicy food and large meals make pain worse. worse. She does notice that she has increased
Aggravating Factors: eating, lying down burping after meals. She states that time generally
Relieving Factors: sitting up, waiting makes the pain better, but notes that she does treat
Treatments: antacid every few days the pain “every few days” with an over the counter
antacid with some relief.
Allergies:
Cats- sneezing, itchy eyes and asthma exacerbation Social History: She denies any specific changes in
Penicillin- rash, hives her diet recently, but notes that she has increased
her water intake. Breakfast is usually a muffin or
Medications: pumpkin bread, lunch is a sandwich with chips,
Flovent 110mcg, 2 puffs bid, last used this morning dinner is a homemade meal of a meat and
Proventil 90mcg, 2 puffs every 4-6 hours prn vegetable, snacks are French fries or pretzels. She
shortness of breath, last used 3 months ago denies coffee intake, but does drink diet cola on a
Tums, 2-4 tabs, last used yesterday after dinner regular basis. She denies use of tobacco and illicit
Tylenol 500mg tab, 500-1000mg (1-2 tabs) po q4h drugs. She drinks alcohol occasionally, last was 2
prn headache. weeks ago, and was 1 drink. She does not exercise.
Ibuprofen 200mg tab, 600mg (3 times) po tid prn
cramps, last used 1 month ago Review of Systems: General: Denies changes in
weight and general fatigue. She denies fevers, chills,
PMHx: and night sweats. • Cardiac: Denies a diagnosis of
Asthma- dx age 2 1/2 yo hypertension, but states that she has been told her
Diabetes Type 2- dx age 24 yo blood pressure was high in the past. She denies
This study source was downloaded by 100000770861734 from CourseHero.com on 02-18-2022 03:32:27 GMT -06:00
known history of murmurs, dyspnea on exertion,
https://www.coursehero.com/file/36094919/Gastrointestinal-Physical-Assessment-Assignment-Documentationpdf/
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