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

Shadow health tina jones abdominal assessment

31/12/2020 Client: saad24vbs Deadline: 3 days

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:

Top Essay Tutor
Homework Guru
Best Coursework Help
University Coursework Help
Helping Hand
Writer Writer Name Offer Chat
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
Homework Guru

ONLINE

Homework Guru

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

$62 Chat With Writer
Best Coursework Help

ONLINE

Best Coursework Help

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
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

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

Similar Homework Questions

Fermi problems and solutions - Strategic audit example - All of the following are sources of internal recruiting except - Donnie brasco cancer of the prick - Core concepts 3.3 word wise - Motor vehicle repair licence - Han emperors in china worksheet answers - Do managers matter - Te whare tapa wha - How to get textbook answers for free - Alpha and beta bias - Tenable sc system requirements - Abc des moines channel - Skinner labeled unlearned reflexes or stimulus-response connections as - Grey goose target audience - Jane elliott's blue eyes brown eyes exercise - Statement of intent examples - Use case diagram for pizza ordering system - Sodium carbonate can be prepared by heating sodium bicarbonate - Ukkadai thevar net worth - Week 7 discussion - Waves and vibrations lab answer key - How do you make 0.01 n hcl - Rhetorical Analysis - Ortho neuro columbus ohio - Health Information technology presentation - Why is this a problem? - Ati active learning template basic concept management of care - Should cellphones be allowed in school essay - Vce chinese second language character list - Economic Assignment - The project scope document is valuable for establishing - Code of chivalry meaning - Allison automatic fault codes - Data commentary in academic writing - Dehydration powerpoint presentations - Control activities under sas 109 coso include - Jack carter pool rules - Emergent properties of ecosystems - Peter symonds current students - Hp envy 750qd desktop pc - Projet 1 - Pool fence non-climbable zone vic - Swan hill police scanner - Personal leadership philosophies - Christopher little net worth - Help- 6 pages excluding citations - Baron maxime brut gold reserve 2016 price - Global dimension of management - Walmart supplier sustainability questions for suppliers - Factset excel add in - Religion - Anchorage port stephens accommodation - Coll 148 week 4 quiz - Sunbus com au townsville - A rocket blasts off and moves straight upward - When you squeeze an air filled balloon what happens inside - Exercise g1 1 subject verb agreement answers - Codes of ethics comparative chart - Lake tali karng hike map - Unit 1 Discussion - Oxidation and reduction lab report - The stock of nogro corporation is currently - Course Reflection Guidelines Nursing an the aging process - Only remembered for what we have done lyrics - Police Technology - 1 4 9 16 pattern - Lincoln and guba 1985 trustworthiness of the study - Homework - Mp3 - Western avenue carpark usyd - Swinton and pendlebury local history society - Describe and evaluate the behaviourist approach - Jacques a dit game - 63 divided by 3 - Their eyes were watching god simply beautiful - Fideco usb 3.0 hdd docking station - Cisco rv220w network security firewall price - Boeing 737 take off procedures - Hellenistic Anatomy and Physiology - Be glad your nose is on your face pdf - Chapter 22 enlightenment and revolution - Discussion - Sgic com au calculators - Three aspects of wu wei - Mass communication living in a media world 7th edition - Faces edges and vertices of cube - Harley davidson ethnocentric company - Was it necessary to re formulate new coke - Applications of distributed database system pdf - Florida villa holidays 2015 - Bc chemistry 12 answer key - Slump test procedure astm - Chinua achebe an image of africa - Leadership and the one minute manager cliff notes - Yp dual rate formula - How many gallons of gas for 600 miles - Virgin america market segmentation - 5 advantages and disadvantages of project delivery methods - Aalsmeer flower auction perfect competition