12/10/2020 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
Gastrointestinal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2020
Return to Assignment
Your Results Lab Pass
Documentation
Overview
/ 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
Review Questions HPI: Ms. Jones is a pleasant 28-year-old African
Patient info: Tina Jones, 28, African-American American woman who presented to the clinic with
Female complaints of upper stomach pain after eating. She
Self-Reflection
noticed the pain about a month ago. She states that
CC: frequent stomach pain she experiences pain daily, but notes it to be worse
3-4 times per week. Pain is a 5/10 and is located in
HPI: her upper stomach. She describes it “kind of like
Onset: Pain has been happening for "at least a heartburn” but states that it can be sharper. She
month" and getting worse with time, notes it to increase with consumption of food and
specifically fast food and spicy food make pain
Location: Upper stomach, "under the breastbone". worse. She does notice that she has increased
Does not radiate. burping after meals. She states that time generally
makes the pain better, but notes that she does treat
Duration: Pain occurs everyday with 3 to 4 episodes the pain “every few days” with an over the counter
a week that are worse. Pain starts 10 to 15 minutes antacid with some relief.
after eating and lasts "a few hours".
Social History: She denies any specific changes in
Characteristics: Pain at the worst is "6 or 7" out of her diet recently, but notes that she has increased
10. Pain is similar to heartburn. her water intake. Breakfast is usually a muffin or
pumpkin bread, lunch is a sandwich with chips,
Aggravating Factors: Eating, especially larger meals dinner is a homemade meal of a meat and
or spicy foods. Pain is worse when lying down or vegetable, snacks are French fries or pretzels. She
bending over. denies coffee intake, but does drink diet cola on a
regular basis. She denies use of tobacco and illicit
Relieving Factors: Time between meals, sitting drugs. She drinks alcohol occasionally, last was 2
upright weeks ago, and was 1 drink. She does not exercise.
Treatment: OTC Antacids (Tums) Review of Systems: General: Denies changes in
weight and general fatigue. She denies fevers, chills,
Current Medications: OTC Tums to relieve stomach and night sweats. • Cardiac: Denies a diagnosis of
pain. Reports that she takes between 2 to 4 "every hypertension, but states that she has been told her
few days". Patient is not taking any other new blood pressure was high in the past. She denies
1/4
, 12/10/2020 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
known history of murmurs, dyspnea on exertion,
2/4
Gastrointestinal Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2020
Return to Assignment
Your Results Lab Pass
Documentation
Overview
/ 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
Review Questions HPI: Ms. Jones is a pleasant 28-year-old African
Patient info: Tina Jones, 28, African-American American woman who presented to the clinic with
Female complaints of upper stomach pain after eating. She
Self-Reflection
noticed the pain about a month ago. She states that
CC: frequent stomach pain she experiences pain daily, but notes it to be worse
3-4 times per week. Pain is a 5/10 and is located in
HPI: her upper stomach. She describes it “kind of like
Onset: Pain has been happening for "at least a heartburn” but states that it can be sharper. She
month" and getting worse with time, notes it to increase with consumption of food and
specifically fast food and spicy food make pain
Location: Upper stomach, "under the breastbone". worse. She does notice that she has increased
Does not radiate. burping after meals. She states that time generally
makes the pain better, but notes that she does treat
Duration: Pain occurs everyday with 3 to 4 episodes the pain “every few days” with an over the counter
a week that are worse. Pain starts 10 to 15 minutes antacid with some relief.
after eating and lasts "a few hours".
Social History: She denies any specific changes in
Characteristics: Pain at the worst is "6 or 7" out of her diet recently, but notes that she has increased
10. Pain is similar to heartburn. her water intake. Breakfast is usually a muffin or
pumpkin bread, lunch is a sandwich with chips,
Aggravating Factors: Eating, especially larger meals dinner is a homemade meal of a meat and
or spicy foods. Pain is worse when lying down or vegetable, snacks are French fries or pretzels. She
bending over. denies coffee intake, but does drink diet cola on a
regular basis. She denies use of tobacco and illicit
Relieving Factors: Time between meals, sitting drugs. She drinks alcohol occasionally, last was 2
upright weeks ago, and was 1 drink. She does not exercise.
Treatment: OTC Antacids (Tums) Review of Systems: General: Denies changes in
weight and general fatigue. She denies fevers, chills,
Current Medications: OTC Tums to relieve stomach and night sweats. • Cardiac: Denies a diagnosis of
pain. Reports that she takes between 2 to 4 "every hypertension, but states that she has been told her
few days". Patient is not taking any other new blood pressure was high in the past. She denies
1/4
, 12/10/2020 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health
known history of murmurs, dyspnea on exertion,
2/4
