Course Hero, Inc. Screening/Risk Assessment – Identified health concerns based on screening assessments and demographic information Nutrition/Activity Pain is a 5/10 and is located in, her upper stomach. Tympanic throughout. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. She drinks alcohol occasionally, last was 2. weeks ago, and was 1 drink. Review of Systems: General: Denies changes in. She is alert and oriented. DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. She states that, she experiences pain daily, but notes it to be worse, 3-4 times per week. This preview shows page 1 - 2 out of 4 pages. She denies coffee intake, but does drink diet cola on a regular basis. 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. Shadow Health Gastrointestinal Documentation Documentation / Electronic Health Record • Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation 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 denies. NB: We have all the questions and documented answers in the SUBJECTIVE DATA, OBJECTIVE DATA, ASSESSMENT AND CARE PLAN format. Discuss the components of a focused gastrointestinal assessment. Summary - shadow health gastrointestinal physical assessment review questions 35. She describes it kind of like heartburn but states that it can be sharper.   Terms. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. To patients, the word 'stomach' can mean anywhere from the diaphragm to the groin and includes the genitals. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She denies coffee intake, but does drink diet cola on a regular basis. Chief Complaint. 'Do you have a hard stool?' Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. Asked about onset of pain Reports chest pain started appearing in the past month. Shadow Health will grade you on what you ask and will deduct points for what you omitted. She noticed the pain about a month ago. No known jaundice, problems with liver or spleen. known history of murmurs, dyspnea on exertion. She denies use of tobacco and illicit drugs. She noticed the … The following details are facts of the patient's case. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. She denies fevers, chills, and night sweats. Bowel movements are daily and generally brown in color. Pain is a 5/10 and is located in her upper stomach. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. Hunter College CUNY. She denies fevers, chills, and night sweats. She noticed the pain about a … Breakfast is usually a muffin or. She does not exercise. Review of Systems: General: Denies changes in weight and general fatigue. Duration: Pain occurs everyday with 3 to 4 episodes, a week that are worse. Pain starts 10 to 15 minutes, Characteristics: Pain at the worst is "6 or 7" out of, Aggravating Factors: Eating, especially larger meals, or spicy foods. Useful guide for Chamberlain students in the United States. A combination of open and closed questions will yield better patient data. Hope that helps. Pain is a 5/10 and is located in her upper stomach. dvanced ealth ssessment health history tina got this scrape on my foot while ago, and thought it would heal up on its own, but now looking pretty nasty. Make sure that you understand what the patient means and get amplification of specific points. Spleen and bilateral kidneys are not palpable. reports frequently occurring stomach pain, how many times a week does your stomach hurt, reports 3-4 episodes a week that are more severe, how long after a meal does the pain start, how many hours does the stomach pain last, center of upper stomach, below the breasbone, doesn't want to eat out of anticipation of pain, what medications do you take for stomach pain, do you have trouble holding your urine in, what was your most recent meal and what did you eat, how many times a week do you drink alcohol, do you think you could have food poisoning, how far away is the grocery store from you, do you have nausea, vomiting, diarrhea, constipation, bloating, do you have sore throat, coughing, dysphagia, difficulty breathing, chest pain, palpitations, change in taste, family history of GERD, IBS, cholecystitis, liver/kidney/bladder disease. N522 Assignment 4 physical assessment – Focused Note - Esther ParkAfter you complete the focused assessment (virtual simulation), please write a paper using the following as headings/subheadings in APA format.Introduction (with purpose statement – one paragraph)Focus of the Assessment (i (Abdominal Pain) Pre Brief: Ms. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain.She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. – Education level (health literacy) – Access to health care Insurance/Financial status – Is the patient able to afford medications and health diet, and other out-of-pocket expenses? NR 509 Week 1 Assignment Debriefing . University. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify … 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. NR 509 Gastrointestinal Documentation Shadow.pdf - Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health Gastrointestinal Physical, 814 out of 839 people found this document helpful, Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health, Gastrointestinal Physical Assessment Assignment Results | Turned In, Advanced Health Assessment - Chamberlain, NR509-October-2018, Patient info: Tina Jones, 28, African-American, Onset: Pain has been happening for "at least a. 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. Presenting to shadow health hospital clinic for a complete health assessment for a pre-employment physical. She, denies coffee intake, but does drink diet cola on a, regular basis. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. Course Hero is not sponsored or endorsed by any college or university. 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. No blood in emesis. She does notice that she has increased burping after meals. Advnc Health Assessm (NURS 751.00) … She noticed the pain about a month ago. No bruits with auscultation over abdominal aorta. Denies any change in stool color, consistency, or frequency. Avoid technical terms, jargon or abbreviations. She does notice that she has increased, burping after meals. and the . • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. Asked about location of pain Reports pain is in center of the chest … No tenderness to light or deep palpation. 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 … • Cardiac: Denies a diagnosis of, hypertension, but states that she has been told her, blood pressure was high in the past. She describes it "kind of like heartburn" but states that it can be sharper.   Privacy She denies use of tobacco and illicit, drugs. During the debriefing process, students reflect upon their simulation experience and … Gastrointestinal | Completed | Shadow Health 5.pdf, NR 509 Abdominal Pain Documentation Shadow.pdf, Esther Parks _Abdominal Pain _ Objective.Data_ Shadow Health.pdf, NR 509 Abdominal Pain Objective Shadow.pdf, NR 509 Abdominal Pain Subjective Shadow.pdf, California State University, Long Beach • NURSING 305, Gastrointestinal Physical Assessment Assignment _ Documentation.pdf, Shadow Health Gastrointestinal Documentation.docx, Gastrointestinal Results...DOCUMENTATION.PDF.docx, Copyright © 2021. Patient is not taking any other new, medications other than her inhalers and OTC pain, 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. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Location: Upper stomach, "under the breastbone". She states that she experiences pain daily, but notes it to be worse 3-4 times per week. The date, time, and duration of the weekly debriefing session will be posted by the course faculty. She, noticed the pain about a month ago. Students must register to attend the debriefing session. Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment. No Social drinker (rarely) 2 or less/day 3 or greater/ day Do you use recreational drugs? Pain is worse when lying down or, Relieving Factors: Time between meals, sitting, Current Medications: OTC Tums to relieve stomach, pain. She describes it “kind of like, heartburn” but states that it can be sharper. No Yes ____years History of drug abuse? The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. stomach pain after eating. • Respiratory: Chest is symmetrical with respirations. Social History: She denies any specific changes in her diet recen but notes that she has increased her water intake. Introduce yourself – name / role Confirm patient details – name / DOB Explain the need to take a history Gain consent Ensure the patient is comfortable • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. 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 use of tobacco and … Do you drink alcohol? Critically appraise the findings as normal or abnormal. 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