Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Abdominal assessment shadow health

08/01/2021 Client: saad24vbs Deadline: 2 Day

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


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.


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


Overview


Transcript


Subjective Data Collection


Objective Data Collection


Education & Empathy


Documentation


Document: Provider Notes


https://aspen.shadowhealth.com/assignments/313476/

https://aspen.shadowhealth.com/assignment_attempts/6541639/lab_pass.pdf

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.


Comments


If your instructor provides individual feedback on this assignment, it will appear here.


© Shadow Health 2012 - 2020 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents


(https://www.shadowhealth.com/patents)


®


https://support.shadowhealth.com/

https://aspen.shadowhealth.com/static/terms_of_service

https://aspen.shadowhealth.com/static/privacy_policy

https://www.shadowhealth.com/patents

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

University Coursework Help
Helping Hand
Top Essay Tutor
Smart Accountants
Writer Writer Name Offer Chat
University Coursework Help

ONLINE

University Coursework Help

Hi dear, I am ready to do your homework in a reasonable price.

$62 Chat With Writer
Helping Hand

ONLINE

Helping Hand

I am an Academic writer with 10 years of experience. As an Academic writer, my aim is to generate unique content without Plagiarism as per the client’s requirements.

$60 Chat With Writer
Top Essay Tutor

ONLINE

Top Essay Tutor

I have more than 12 years of experience in managing online classes, exams, and quizzes on different websites like; Connect, McGraw-Hill, and Blackboard. I always provide a guarantee to my clients for their grades.

$65 Chat With Writer
Smart Accountants

ONLINE

Smart Accountants

I feel, I am the best option for you to fulfill this project with 100% perfection. I am working in this industry since 2014 and I have served more than 1200 clients with a full amount of satisfaction.

$55 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

Liberty university transcript evaluation - Indian camp ernest hemingway pdf - Thanh hoang nguyen missing san francisco - What are the five process groups of project management - ACC 305 Intermediate Accounting I - FOIA/Privacy Act Matrix - Bsg quiz 2 answer key - The castle school taunton staff - Beaumont lodge medical practice - Hoxton park high school leny wallace - The story factory production company - Nuffield dyspraxia programme manual - Achieving excellence in fundraising pdf - Lab report chemistry basic laboratory techniques - Ojr friends of the arts craft show - ET410 Procter Exam Questions - Caught in the croud - A tale of two restaurants case study answers - Red bull stratos marketing case study - Executive summary network design proposal - Introduction to programming using python y daniel liang pdf - Aj sadler mathematics specialist solutions - 86 main street kempton - Water by the spoonful full pdf - Supplies balance sheet or income statement - Helping verbs have has had worksheet - What intended victim of macbeth's plot manages to escape - Biosecurity and bioterrorism - Assignment - Retrospective Research Proposal Follow the guidelines example provided under attachment - Wk 3 acct - The greatest showman dvd ireland tesco - Tutor Account On Sale - Free leadership legacy assessment test or disc personality test - Math connections answer key science - Beck manufacturing and plant capacity - Disadvantages of brinell hardness test - Disney informative speech outline - Theories of Development Case Study X2 - Assessment 4 - Environmental sciences - Situational irony in the story of an hour - 3711 san gabriel mission tx 78572 - What is a6 size - Ops 571 week 5 individual assignment operations forecasting - The financial industry uses business intelligence to predict hardware failures - 3 sol to aud - Customer involvement is on a b2c specialty purchase - What is family development theory - Assign - Calculus business discussion question #1 - Finally September 2020 - List and explain 2 opportunities and also list some challenges that might arise for RNs and APRNs as they actively participate in policy review finally describe how you might overcome these challenges.  - A house for hermit crab lesson plans kindergarten - Walden's mission of social change - A grandfather pendulum clock keeps perfect time - Pr007 work product - Aqa gcse english literature specification - Moodle kent ac uk - Save our sea turtles - Case 1-8 Shifty Industrie - Homework for lab 5 force mass and acceleration answers - Identify learning styles and generational characteristics - Example of nursing process case study - Cyber vetting - Glenn colquhoun bred in south auckland - 13 colonies quiz questions - Conduction mode of heat transfer - 400 word blog project soc350 - Describe the moment captured in leonardo's last supper painting - Signature Assignment: Medicare and Medicaid - The real leadership lessons of steve jobs harvard business review - Which ethical system embraces human's inclination for self preservation - 3837 bay lake trail las vegas nevada - Faye sayer time team - Munro by kresley cole release date - Dr con archis hurstville - Career counseling code of ethics - Passcode for windy city smokeout - Advantages and disadvantages of non renewable resources - Lindner fund v abney - Jfk stadium philadelphia demolition - Expert grill turkey fryer timer bypass - Soap note for strep throat - The hart surgery henley - How to install elfa easy glider - Titanic engineering failure - Contemporary Business Leaders - Ethical theory comparison chart - Business studies 2013 hsc answers - Writing routine and positive messages in business communication - Maths frameworking homework book 2 - Discussion 2 - 7 grammar mechanics checkup 4 adjectives and adverbs - Do cell phones cause distractions in school - Math 251 8 assignments - Causes of perceptual distortion - Common stock without par value - Jodee berry now - Baba the cosmic barber died