12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
Gastrointestinal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Lifespan
Subjective hDeorciunmhaenletarstioann-dShOadToCwppdafi/n
Review Questions
Patient info: Tina Jones, 28, African-American
Female
Self-Reflection
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
https://www.coursehero.com/file/36351797m/NeRd-ic5a0t9i-oGnasstortohinetresthtiannal-
https://chamberlain.shadowhealth.com/assignment_attempts/4249614 1/4
, 12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
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,
https://chamberlain.shadowhealth.com/assignment_attempts/4249614 2/4
Gastrointestinal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Lifespan
Subjective hDeorciunmhaenletarstioann-dShOadToCwppdafi/n
Review Questions
Patient info: Tina Jones, 28, African-American
Female
Self-Reflection
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
https://www.coursehero.com/file/36351797m/NeRd-ic5a0t9i-oGnasstortohinetresthtiannal-
https://chamberlain.shadowhealth.com/assignment_attempts/4249614 1/4
, 12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
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,
https://chamberlain.shadowhealth.com/assignment_attempts/4249614 2/4
