NR509 Gastrointestinal Physical Assessment Assignment

NR509 Gastrointestinal Physical Assessment Assignment. CC: Abdominal pain Onset: 1 month ago Location: mid-upper abdomen, below breast bone (epigastric area) Duration: a few hours, occurs after eating Characteristics: "feels like heartburn", describes as a burning feeling but sharper. Hurts a little after each meal, 3-4 times a week it's bad. Currently pain 1- 2/10, after eating pain is 5/10. Also has burping after eating. Spicy food and large meals make pain worse. Aggravating Factors: eating, lying down Relieving Factors: sitting up, waiting Treatments: antacid every few days Allergies: Cats- sneezing, itchy eyes and asthma exacerbation Penicillin- rash, hives Medications: Flovent 110mcg, 2 puffs bid, last used this morning Proventil 90mcg, 2 puffs every 4-6 hours prn shortness of breath, last used 3 months ago Tums, 2-4 tabs, last used yesterday after dinner Tylenol 500mg tab, 500-1000mg (1-2 tabs) po q4h prn headache. Ibuprofen 200mg tab, 600mg (3 times) po tid prn cramps, last used 1 month ago PMHx: Asthma- dx age 2 1/2 yo Diabetes Type 2- dx age 24 yo 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, We offer online tutoring, help with assignments and essay writing for all majors with a guaranteed pass. For assistance Contact Tutor Lucas: +1