Gastrointestinal Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509 SHADOW HEALTH

Gastrointestinal Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment 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,