Gastrointestinal Documentation EHR- Tina Jones Shadow Health Questions & Answers | Latest Update | Graded A+

Gastrointestinal Results | Turned InD028 - Advanced Health Assessment - August 2023, D028 Return to Assignment Your Results Reopen Lab Pass  Overview  Transcript  Subjective Data Collection  Objective Data Collection  Education & Empathy  Documentation Documentation / Electronic Health Record  Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective stomach pain 1-2 at least 1 month ago, increases gradually takes antacids 3-4 episodes a week lasts few hours denies gi history or diseases grandfather died of colon ca pain after eating worsens w larger meals worsens w spicy food feels better w smaller meals and sitting up 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, orthopnea, paroxysmal nocturnal dyspnea, or edema. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, and constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequency. Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen. Objective no tenderness noted LMP 3 weeks ago General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs,