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Tina Jones Gastrointestinal Documentation
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Student Documentation Model Documentation Subjective Ms. Jones is a pleasant 28 y/o African American woman presenting with complaints of upper stomach pain after eating x1 month. She states the pain is daily after every meal but 3-4 times a week it is worse. She rates the pain 5/10. She describes the pain as "kind of like heartburn" but it is sometimes shaper. She says eating makes it worse. She has noticed increased burping following meals. She said that antacids and time make it better. She is taking the antacids "every few days" which provide some relief. She denies any changes to her diet but notes that she has been eating less to avoid the pain and she has increased her water intake recently. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich and chips, dinner is a homemade meal and vegetables, and snacks consist of French fries or pretzels. She denies coffee intake but reports drinking about 4 diet cokes per day. She denies tobacco and illicit drug use. She drinks occasionally. She does not exercise. Denies any recent changes in weight. Denies fever, chills, night sweats, fatigue. Denies a diagnosis of hypertension but states she has been told she has high blood pressure in the past. Denies any heart conditions. Denies any cough or sore throat. she has a history of asthma which she uses an inhaler for. She was hospitalized for asthma last at age
Student Documentation Model Documentation foods are causing her symptoms. I would educate her on decreasing dietary fat and to avoid eating 2-3 hours before bed time. I would encourage her to remain upright for at least 30 minutes after each meal. I would refer her to dietary for a consult and to a GI specialist for the upper endoscopy. I will have Tina follow up in the clinic in 2 weeks but I will instruct her to seek immediate medical attention if she has s/s of GI bleed, weight loss, or chest pains. 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.