Tina Jones Gastrointestinal 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 noticed the pain about a month ago. She states that she experiences ...

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. This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 05:36:07 GMT -05:00 https://www.coursehero.com/file/47999252/GI-Tina-Jones-documentationdocx/ • 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. No blood in emesis. No known jaundice, problems with liver or spleen. Objective Liver span found at 7cm from costal margin. No complaint of tenderness in all quadrants. Liver palpable at 2 cm from costal margin. No masses, no guarding, no distention. All areas of abdomen normal to auscultation. All blood vessels normal to auscultation. Stomach tympanic throughout. Spleen not palpable. Bilateral kidneys not palpable. 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. This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 05:36:07 GMT -05:00 https://www.coursehero.com/file/47999252/GI-Tina-Jones-documentationdocx/ • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. Assessment Patient has uncontrolled diabetes that is causing polydipsia and polyuria. Patient needs to make adjustments to her diet, as she is consuming too many carbs. Her pain is below the breastbone, and worsens when she eats. It appears that the patient is suffering from increased acid production, as she is burping and hurting when eating. I would treat her for GERD. Gastroesophageal reflux disease without evidence of esophagitis Plan Treat patient for GERD with histamine 2 receptor antagonist, since she is using antacids more than once a week. Educate patient on appropriate diet for diabetes. Have patient follow up in two weeks. If histamine 2 receptor antagonists do not work, will try proton pump inhibitors. 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 wedgeshaped 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 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 This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 05:36:07 GMT -05:00 https://www.coursehero.com/file/47999252/GI-Tina-Jones-documentationdocx/ symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain. • Return to clinic in two weeks for evaluation and follow up. 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. • This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 05:36:07 GMT -05:00 https://www.coursehero.com/file/47999252/GI-Tina-Jones-documentationdocx/ 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, bron