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Exam (elaborations)

BEST REVIEWS FOR Brenda James gastrointestinal issues Complete and Verified 2025/2026

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Health science
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Uploaded on
February 3, 2025
Number of pages
8
Written in
2024/2025
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BEST REVIEWS FOR Brenda James gastrointestinal
issues Complete and Verified 2025/2026
1. Whatbringyouin today?
2. Whereisabdominal pain?
3. Howsevereis thepainonyourstomach?
4. Howlong haveyou had thepain?
5. Whendidthepainstart?Doesthepainradiatesomeplaceelse?
6. Isthepainconstant or intermittent?
7. Anyrecenthospitalizationorsurgeries?
8. Haveyoueverhadabdominalsurgery?
9. Haveyoueverhadthispain before?
10. Anythingmakesthepainbetteror worse?
11. Doyou havenauseaor vomiting?
12. Doyou haveblackor bloody stool?
13. Doyouhavediarrheaorchangeinbowel habits?
14. DoyouhaveAnyallergy?
15. Anythingfoodtrigger pain?
16. Doyouhaveahistoryofdiverticulitis,pancreatitis,kidneyfailure,gallstones
inflammatory bowel disease?
17. Areyoutaking antibioticsorsteroids?
18. Howis yourappetite?Anywightgain orlost?
19. Doyouuseanyantiacidsmedication?
20. Howis yourdiet?
21. Anyfever?
22. Doyou drinkany alcoholor smoke?
23. Doyouhaveahistoryofvascularorheartdisease,hypertension,oratrial fibrillation?
24. Howisyourparents’health?
25. Haveyou hadany morestress inyourlifelately?
26. Whenislastperiod?
27. Doyouhaveyourimmunization up to date?
28. Doyou haveany other symptomsorconcerns weshould discuss?




CC:“Stomachhurting lasttwodays,haven’tabletogoto work.”


HPI:LtColBrendaJamesisa48-year-oldfemalepresentingwithachiefcomplaintofcrampy,
gnawing,achiness fortwodays.Shestartedherpainanddiscomfortlocalizedatherrightupper
anteriorabdomenunderherlowerribs.Thepainexacerbatedwhenshetakedeepbreathing.She
statesthatshehashad asimilarpainstartafewmonthsagothatdiscomforthascomeandgone. However,
her abdomen pain has been constant for the last two days. She reports that the pain radiates to her
right shoulder but did not recall any inciting event when this pain began, but the

, pain oftheevent worsened after she ate, especially eating fast food. She reports shetried taking
antacids over-the-counter medication, but it does not alleviate that issue. She currently rates her
pain3to4outof10,butshehasexperiencedthepainasbadas a6to7.Shealsostatedthatlast two days, she
feels feverish, although she has not taken her temperature.

Furthermore,she reports 15lbs.weightlosscomparedwithfour monthsagoDr.visit.Shestated
shehasnoappetite,threeepisodesofemesisoverthepasttwodays,andbowelmovementssince
toalightercolorrecently.Shereportsahistoryofheartburnanddescribeshercurrentdiscomfort as
feeling noticeably different from her previous heartburn episodes. The patient also has had
arthritis, and she is taking 400 mg of Ibuprofen three times a day as needed for knee pain.




ROS: Constitutional: Brenda James, a 48-year-old female, tall is 5’6’, weight 170lb, mild obesity,
present with right upper abdomen pain, has nausea, vomiting, weight loss, pale stools, pain with deep
breathing, and felt feverish. Denies constipation, hematemesis, yellowing of the skin, abdominal trauma,
breasttenderness,chestpain,swellingdifficultyorswallowing,deniednightsweats,changesorpainwith
urination, any change in the amount of physical activity, any change in frequency of bowel movement.

• HENT:Negative

• Eyes:Negative

• Respiratory:Negative

• Cardiovascular:Negativeforchestpain

• Gastrointestinal:Positiveforabdominalpain,Positivefornauseaandvomiting

• Genitourinary:negative

• Musculoskeletal:Positiveforarthralgiasandmyalgia,arthritiskneepaininlowerback pain
from past injury, denied other joint pain, joints swelling, muscle cramps, muscle
weakness, stiffness.

• Skin:Skinintact

• Neurologic:deniestransientparalysis,paresthesia,seizures,syncope,tremors,vertigo.

• Psychiatric/Behavioral:Negative

• Endocrine:deniescoldintolerance,heatintolerance,polydipsia,polyphagia,polyuria

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