Tina Jones Gastrointestinal Subjective

Tina Jones Gastrointestinal Subjective Assignment

Gastrointestinal Results | Completed Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1


Return to Assignment (/assignments/313476/)


App.shadowhealth.com is currently experiencing slow response times. Our engineers are currently investigating the issue.


Documentation / Electronic Health Record


Document: Provider Notes


Student Documentation Model Documentation




this 28 you African pleasant female, presents with complaints of stomach pains that started a month ago. “feels like heartburn” Relieved with antacids, but is getting worse. Pain 1-2 right now, but a 5/10 after eating. Eating makes it worse. Sitting up helps. PMH: diabetes: no meds: Asthma: on proventil and albuterol: controlled Social hx: hx of THC use, none now. drinks 3-4 cans of soda in a day. ROS: heart burn normal form of stools, no diarrhea or constipation : Denies mental health issues: FMK PGF with colon cancer Diet: lots of fried and fast food: Exercise: limited


HPI: Ms. Jones is a pleasant 28-year-old African American woma who presented to the clinic with complaints of upper stomach pa 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 time per week. Pain is a 5/10 and is located in her upper stomach. Sh describes it “kind of like heartburn” but states that it can be shar She notes it to increase with consumption of food and specifical fast food and spicy food make pain worse. She does notice that has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “ev few days” with an over the counter antacid with some relief. Social History: She denies any specific changes in her diet recen but notes that she has increased her water intake.


Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chip dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink cola on a regular basis. She denies use of tobacco and illicit drug She drinks alcohol occasionally, last was 2 weeks ago, and was drink. She does not exercise. Review of Systems: General: Denies changes in weight and gene fatigue. She denies fevers, chills, and night sweats.


  • Cardiac: De a diagnosis of hypertension, but states that she has been told he blood pressure was high in the past. She denies known history o murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturna 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 wa age 16, last chest XR was age 16.


  • Gastrointestinal: States that general her appetite is unchanged, although she does note that s will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, a constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequenc Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen.

Get Tina Jones Gastrointestinal Subjective Assignment Help

Your Results Lab Pass (/assignment_attempts/6541639/lab_pass.pd






Subjective Data Collection


Objective Data Collection


Education & Empathy




Document: Provider Notes


Student Documentation Model Documentation




Skin Turgor : no tenting Lungs; CTA: Heart: Normal S1, S2 sounds. no murmur Abdominal : round, distended, discoloration, striae, no scars noted, symetrical. normal bowel sounds, no organomegly or rebound tenderness Liver palpable 1cm below right costal margin: Liver percussion with 7cm span in the mid-clavicular line. Spleen: not palpable: no tenderness Kidney: No CVA tenderness, not palpable


General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination.

• Abdominal: Abdomen is soft and protuberant without scars or s lesions; skin is warm and dry, without tenting. Bowel sounds pre and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 below the right costal margin. Spleen and bilateral kidneys are no palpable. No CVA tenderness.

• Cardiovascular: Regular rate and rhythm, S1 and S2 present, n murmurs, rubs, gallops, clicks, precordial movements. No bruits auscultation over abdominal aorta. No femoral, iliac, or renal bru

• Respiratory: Chest is symmetrical with respirations. Lung sound clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough.




Heartburn Possible GERD


Gastroesophageal reflux disease without evidence of esophagitis




Discuss diet and avoiding fried, spicy, and soda foods. Exercise regimen encouraged Daily activy encouraged Take small frequent meals Consider Zantac if needed F/u in one week with above regimen. consider h-phyloric IGG/IGM if persistent sx Return to clinic if symptoms worsen, bloody stools RT hospital if chest pain


Educate on lifestyle changes including weight loss, engagement daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcoh and spicy foods.


  • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduc


  • Encourage to eat smaller meals and to avoid eating 2-3 hours before bedtime.


  • Educate on dietary reduction in fat to decrease symptoms.


  • Trial of ranitidine 150 mg by mouth daily for two we If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, consider testing for helicobacter pylori, trial o proton pump inhibitor, or upper endoscopy.


  • Educate on when t seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain.


  • Retur clinic in two weeks for evaluation and follow up.

Order a Custom Paper

Quality Assignments Help Website

Cost of your order


Why Choose Us

Top Quality and Well-Researched Papers

We ensure that all your instructions are followed to the letter. You are able to choose the level of interest; professional, college, or high school. We will assign a writer who will cover all your specifications.

Professional and Experienced Academic Writers

We have a team of well trained and experiences assignment writers who are PhD and master’s holders. Our writers are can handle more than 91 disciplines.

Free Unlimited Revisions

If your assignment is not covered to your expectation, you can send your order for revision. The order should be submitted before 10 days elapses for review You can contact our support team or login to your personal account to submit your request.

100% Money-Back-Guarantee

We ensure on-time delivery of your papers. For clarification purpose, we may contact you regarding deadline extension. In case you cannot provide us with more time, we guarantee a 100% refund.

Originality & Confidentiality

We use professional tools to ensure all assignment help documents you receive are free of plagiarism. Our editors ensure optimum review of all quotations in the text. We also ensure confidentiality in our service delivery.

24/7 Customer Support

Our team of experts is available 24/7 to ensure that you are provided with the top customer experience. Any time you need assignment help, you can reach us and get the best experience with ours services.

Our Services

You don’t have to struggle with your papers. You need ample sleep; our writers will cover you. We provide writing services in all disciplines.


Essay Writing Services

No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.


Admission and Business Papers

An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.


Editing and Proofreading

Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.


Revision Support

If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.