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Student Name: Christa Para
Date: 6/11/2024
Shadow Health Case: Gastrointestinal
SUBJECTIVE:
Patient Name: Tina Jones
VS:
RR: 15
HR: 80
BP: 138/80
SpO2: 98%
Temperature: 99.6 F
Allergies:
Penicillin - Rash and hives
Cats - Wheezing, itchy eyes, runny nose, sneezing
Chief complaint (CC):
“I’ve been having this stomach pain for awhile. It keeps coming back
and it is really starting to bother me”
Medications:
Flovent (110 mcg/spray) MDI 2 puffs BID for asthma
Tums – PRN for heartburn
PMH (include Childhood & Adult Illnesses):
History of asthma and diabetes. She was diagnosed with asthma at
age 2 ½ and prescribed an albuterol inhaler which she uses as needed for
asthma attacks. Was diagnosed with diabetes at age 24 and is
noncompliant with her medication regimen due to feeling overwhelmed with
medication. Reports recently taking an antacid for her abdominal pain.
Denies history of stomach cancer, GERD, irritable bowel syndrome,
inflammatory bowel disease, kidney problems, bladder problems, or liver
problems. Denies history of appendicitis or cholecystitis. Denies past
history of ulcers. Patient reports being up to date on immunizations and
screenings appropriate for age.
Psychiatric History:
Patient denies any psychiatric history but reports increased anxiety related
to stress.
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Obstetrical History:
Patient denies ever being pregnant and denies currently being sexually
active. Reports LMP was about. a month ago.
PSH:
No surgical history
Family Hx:
Patient reports grandfather with history of colon cancer. Denies family
history of stomach cancer, irritable bowel syndrome, GERD, or
inflammatory bowel disease. Denies family history of liver or kidney
disease. Denies family history of cholecystitis.
Social Hx:
Tina reports not being able to tolerate spicy or greasy foods due to
her heartburn symptoms. She reports drinking about 3-4 Diet Cokes a day.
For breakfast she usually has a muffin or pumpkin bread; For lunch, she
has a sandwich and chips or French fries. Dinner is a homemade meat and
vegetable; Snacks are French fries or pretzels. She reports eating out
frequently. She denies the use of tobacco and illicit drugs. She drinks
occasionally, and her last alcoholic drink was two weeks ago but reports
drinking less due to increase in her abdominal pain. She does not exercise.
Patient denies any recent travel or food poisoning. Patient reports she is
able to access fresh foods and lives near a grocery store.
ROS:
General: Denies fever, chills, night sweats, recent weight loss,
fatigue.
CV: Patient denies chest pain or dyspnea. Denies palpitations.
Respiratory: Denies shortness of breath or difficulty swallowing.
Denies sore throat or coughing. Has history of asthma.
Psych: Patient reports increased anxiety and stress but denies
depression.
GI: Patient reports mild to severe upper to mid stomach pain that
feels like heartburn and can be sharp at times. Patient denies nausea or
vomiting. Patient denies irregular bowel movements or changes to her
bowel movement. Denies blood in the stool or black tarry stool. Denies
history of liver problems. Denies kidney problems. Patient reports
decreased appetite due to her pain. Reports bowel movements are every
other day. Denies diarrhea or constipation.
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History of present illness (HPI):
Miss Jones is a 28-year-
old African American
female that presents to
the clinic today
complaining of abdominal
pain after eating. Patient
States pain started about
a month ago and
occurs daily, with severe
episodes occurring once
or twice a week. The pain
is located in the
2026-01-09 Start your exams prepared! Page 3
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Student Name: Christa Para
Date: 6/11/2024
Shadow Health Case: Gastrointestinal
SUBJECTIVE:
Patient Name: Tina Jones
VS:
RR: 15
HR: 80
BP: 138/80
SpO2: 98%
Temperature: 99.6 F
Allergies:
Penicillin - Rash and hives
Cats - Wheezing, itchy eyes, runny nose, sneezing
Chief complaint (CC):
“I’ve been having this stomach pain for awhile. It keeps coming back
and it is really starting to bother me”
Medications:
Flovent (110 mcg/spray) MDI 2 puffs BID for asthma
Tums – PRN for heartburn
PMH (include Childhood & Adult Illnesses):
History of asthma and diabetes. She was diagnosed with asthma at
age 2 ½ and prescribed an albuterol inhaler which she uses as needed for
asthma attacks. Was diagnosed with diabetes at age 24 and is
noncompliant with her medication regimen due to feeling overwhelmed with
medication. Reports recently taking an antacid for her abdominal pain.
Denies history of stomach cancer, GERD, irritable bowel syndrome,
inflammatory bowel disease, kidney problems, bladder problems, or liver
problems. Denies history of appendicitis or cholecystitis. Denies past
history of ulcers. Patient reports being up to date on immunizations and
screenings appropriate for age.
Psychiatric History:
Patient denies any psychiatric history but reports increased anxiety related
to stress.
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Obstetrical History:
Patient denies ever being pregnant and denies currently being sexually
active. Reports LMP was about. a month ago.
PSH:
No surgical history
Family Hx:
Patient reports grandfather with history of colon cancer. Denies family
history of stomach cancer, irritable bowel syndrome, GERD, or
inflammatory bowel disease. Denies family history of liver or kidney
disease. Denies family history of cholecystitis.
Social Hx:
Tina reports not being able to tolerate spicy or greasy foods due to
her heartburn symptoms. She reports drinking about 3-4 Diet Cokes a day.
For breakfast she usually has a muffin or pumpkin bread; For lunch, she
has a sandwich and chips or French fries. Dinner is a homemade meat and
vegetable; Snacks are French fries or pretzels. She reports eating out
frequently. She denies the use of tobacco and illicit drugs. She drinks
occasionally, and her last alcoholic drink was two weeks ago but reports
drinking less due to increase in her abdominal pain. She does not exercise.
Patient denies any recent travel or food poisoning. Patient reports she is
able to access fresh foods and lives near a grocery store.
ROS:
General: Denies fever, chills, night sweats, recent weight loss,
fatigue.
CV: Patient denies chest pain or dyspnea. Denies palpitations.
Respiratory: Denies shortness of breath or difficulty swallowing.
Denies sore throat or coughing. Has history of asthma.
Psych: Patient reports increased anxiety and stress but denies
depression.
GI: Patient reports mild to severe upper to mid stomach pain that
feels like heartburn and can be sharp at times. Patient denies nausea or
vomiting. Patient denies irregular bowel movements or changes to her
bowel movement. Denies blood in the stool or black tarry stool. Denies
history of liver problems. Denies kidney problems. Patient reports
decreased appetite due to her pain. Reports bowel movements are every
other day. Denies diarrhea or constipation.
2026-01-09 Start your exams prepared! Page 2
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prepared!
coverage!
History of present illness (HPI):
Miss Jones is a 28-year-
old African American
female that presents to
the clinic today
complaining of abdominal
pain after eating. Patient
States pain started about
a month ago and
occurs daily, with severe
episodes occurring once
or twice a week. The pain
is located in the
2026-01-09 Start your exams prepared! Page 3
