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Tina Jones GI documentation
Advanced Health Assessment (NURP 530)
Simmons University
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Tina Jones – Gastrointestinal
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective Ms. Jones is a pleasant 28 y/o African American woman presenting with complaints of upper stomach pain after eating x1 month. She states the pain is daily after every meal but 3-4 times a week it is worse. She rates the pain 5/10. She describes the pain as "kind of like heartburn" but it is sometimes shaper. She says eating makes it worse. She has noticed increased burping following meals. She said that antacids and time make it better. She is taking the antacids "every few days" which provide some relief. She denies any changes to her diet but notes that she has been eating less to avoid the pain and she has increased her water intake recently. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich and chips, dinner is a homemade meal and vegetables, and snacks consist of French fries or pretzels. She denies coffee intake but reports drinking about 4 diet cokes per day. She denies tobacco and illicit drug use. She drinks occasionally. She does not exercise. Denies any recent changes in weight. Denies fever, chills, night sweats, fatigue. Denies a diagnosis of hypertension but states she has been told she has high blood pressure in the past. Denies any heart conditions. Denies any cough or sore throat. she has a history of asthma which she uses an inhaler for. She was hospitalized for asthma last at age 16. States that her appetite has not changed but she does experience loss of appetite in anticipation of the pain. Denies nausea/vomiting, Bowel movements are normal with no changes. Denies blood in the stool. Reports increased frequency in urination related to increased water intake. Denies blood in the urine. Denies any known problems with the liver or spleen.
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, orthopnea, paroxysmal nocturnal 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 was age 16, last chest XR was age 16. • Gastrointestinal: States that in general
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her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, and constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequency. Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen.
Objective Ms. Jones is a pleasant, obese, 28 y/o African American woman in no acute distress. She is A&O and maintains eye contact throughout visit. Abdomen is soft and protuberant, no scars or lesions noted. Bowel sounds are present and normoactive in all 4 quadrants. No tenderness or guarding on light or deep palpation. Tympany heard throughout. Liver is 7cm at the MCL and palpable 1cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness noted. Regular rate and rhythm with S1 and S2 present. No murmurs, gallops, rubs, or clicks noted. No bruits with auscultation at the aorta, femoral, iliac, or renal arteries. chest is symmetrical. Lung sounds are clear to auscultation with no wheezes, crackles, rhonchi noted.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. No bruits with auscultation over abdominal aorta. No femoral, iliac, or renal bruits. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough.
Assessment GERD
Gastroesophageal reflux disease without evidence of esophagitis
Plan Take a Proton pump inhibitor by mouth daily for two weeks - likely start her on ranitidine I would want to do an upper endoscopy to check for any issues with her esophagus. I would consider testing for H. pylori if symptoms persist I would educate the patient on lifestyle changes including weight loss, daily physical activity/exercise, identifying and limiting foods that worsen her symptoms such as chocolate, citrus, coffee, alcohol, caffeine, spicy foods, etc. I would have her elevate the head of her bed to help with reducing symptoms. I would have her eating smaller meals and keep a food diary to help determine what
Educate on lifestyle changes including weight loss, engagement in daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcohol, and spicy foods. • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduction. • 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 famotidine 10 mg by mouth twice daily for two weeks. If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, follow up for subsequent recommendations and consider
Tina Jones GI documentation
Course: Advanced Health Assessment (NURP 530)
University: Simmons University
