NSG 516 Gastrointestinal Shadow Health 5 Complete Solution
Advanced Health Assessment - Spring 2019, NSG516 Online
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Patient: Tina Jones
Digital Clinical Experience Score
99.3%
Student Performance Index
49 out of 52
Proficiency Level: Proficient
Beginning Developing Proficient
Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and
clinical reasoning skills. In comparable programs, the
top 25% of students perform at the level of a proficient
practitioner.
This score measures your performance on the Student
Performance Index in relation to other students in
comparable academic programs. Your instructor has
chosen to scale your Student Performance Index score
so that the average score on the index is a 84.0%. This
score may not be your final grade if your instructor
Subjective Data
Collection
30 out of 30
Education and Empathy
2 out of 4
Objective Data Collection
17 out of 18
chooses to include additional components, such as
documentation or time spent. Time
67 minutes total spent in assignment
Interaction with patient
59 minutes
Post-exam activities
8 minutes
Documentation / Electronic Health Record
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Self-Reflection
Student Survey
Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Chief Complaint: I have a stomach pain that keeps
coming bakc and it is starting to bother me.
HPI:
Ms. Jomes is a 28 yr old African American female
who presented with stomach pain that started
approximately one month ago. It was initially minor
but has progressed to a daily occurrence. Its
triggered by food ingestion (spicy food/big meals)
and lasts for a few hours. Pain is rated 1-2/10 in
between meals and 5/10 right after meals with
increased burping. Patient describes the pain is like
a heartburn and it gets worse and feels shart at
times. Pain is located in the center of the stomach.
It gets worse with eating (esp. big meals) which has
resulted in decreased appetite and PO intake,
without notable weight loss. If feels best in between
meals and is improved by sitting up and internittent
antacid use.
Medications:
- Rescue inhaler, Proventil
- Flovent
- Antacid chews
Allergies/RXNS
- Penicillin, Rash
- Cats and dust, sneezing, itching, exacerbates
asthma
ROS
General: Denies fever, chills, weight loss, fatigue.
Respiratory: Denies SOB. Endorses HX of asthma
(currently well controlled).
Gastrointestinal: Denies elimination concerns (BM
Q2days). Endorses increased urination (q2hrs while
awake and more than once during the night). Denies
loose stools, diarrhea, constipation or blood in the
stool. Denies nausea/vomit. Denies flatulence.
Endorses burping. Endorses decreased appetite.
Denies problems with spleen or liver. No jaundice.
Psychologic: Denies depression or anxiety.
Reproductive: Endorses irregular menstruation
(Approximately 6 periods per year)
Family History:
No relevant family history.
Social History:
endorses social drinking, no more
than 6 drinks/month. Denies drinking at all in the
last two weeks.
Tobacco/cig smoking: Denies
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 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.
Other drugs: Denies current use. (+) MJ in high
school
Diet: No recent diet chage. Breakfast: cereal or
toast, muffin or pumpkin bread. Lunch: sandwich
with chips or pretzels, or French fries (not too often).
Dinner: frozen chicken breast, hamburgers,
vegetables and a lot of potatoes and rolls. Drinks:
diet coke and water (increased intake reported)
Exercise: Denies
No blood in emesis. No known jaundice, problems
with liver or spleen.
Objective
Physical Exam:
General: Pleasant, overweight, young woman (28 yr
old) who is relaxed, alert and cooperative. Facial
expression at rest. Pleasant and easy to engage,
able to maintain appropriate eye contact.
VS: 170cm, 87kb BMI 29.4
BP 138/80, HR 80, RR 15, O2sat: 98% and afebrile
(99.6F)
ROS
Respiratory: breath sounds clear and present in all
areas. No adventitious sounds.
Cardiovascular: Adequate turgor (No tenting). S1
and S2 audible. No gallops, murmurs, friction rub or
valve clicks. Abdominal aortic, renal arteries, iliac
arteries or femoral arteries bruit NOT present.
Gastrointestinal: Abdomen symmetric and
protuberant. Bowel sounds present abd
normoactive in all quadrants. All abdomen areas are
tympanic to percussion (no dullness/resonance
noted). No CVA tenderness. Spleen not palpable
and dull to percussion. Liver is 7cm at mid clavicular
line and 1 cm below the right costal margin. No
tenderness/ masses to light or deep palpation.
Kidneys not palbable.
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
This patient has PMH or DM and asthna. She has
been assessed for stomach pain. Her symptoms
prompted a gastrointestinal focused assessment.
Symptoms suggest a diagosis of GERD.
Gastroesophageal reflux disease without evidence
of esophagitis
Plan
- GERD management is based on lifestyle
modifications and control of gastric acid secretion
throught medical therapy.
- Proposed lifestyle modifications: Elevate HOB to 6
fat intake, smoke cessation (N/A),
weight reduction, avoid laying down for 3 hours
after meals, and avoid large meals and triggering
foods (high fat, tomatoes and citrus fruit, chocolate,
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 ranitidine 150 mg by
mouth daily for two weeks. If reduction in
spicy foods, caffeine).
- Pharmacologic therapy: Since PRN antacid was
not addressing her symptoms, pt plan of care
should be escalated to scheduled therapy with OTC
Zantac maximum strength.
- A PPI would be the next option if H2 antagonist
therapy fails.
symptoms, Ms. Jones may continue therapy. If
symptoms persist, consider testing for helicobacter
pylori, trial of a proton pump inhibitor, or upper
endoscopy. • Educate on when to seek emergent
care including signs and symptoms of upper and
lower gastrointestinal bleed, weight loss, and chest
pain. • Return to clinic in two weeks for evaluation
and follow up.
Comments
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