Tina Jones Gastrointestinal Subjective

Tina Jones Gastrointestinal Subjective Assignment

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

 

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Documentation / Electronic Health Record

 

Document: Provider Notes

 

Student Documentation Model Documentation

 

Subjective

 

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.

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Overview

 

Transcript

 

Subjective Data Collection

 

Objective Data Collection

 

Education & Empathy

 

Documentation

 

Document: Provider Notes

 

Student Documentation Model Documentation

 

Objective

 

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.

 

Assessment

 

Heartburn Possible GERD

 

Gastroesophageal reflux disease without evidence of esophagitis

 

Plan

 

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.

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