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Gastrointestinal Patient Case

Gastrointestinal Patient Case 

Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a gastrointestinal problem, but please use the following basic information to document about your patient:

 

Background info (Subjective)

Ms. Chevy is a 22-year-old Caucasian female.

Admitted diagnosis: Abdominal pain and nausea

Past medical history: acne 

Medications include calcium supplement, oral contraceptive pill, new antibiotic for acne

Allergies to Sulfa medications

Substance use- smoker- might want to ask her about her smoking 

Currently: Ms. Chevy is currently at her primary care clinic complaining of abdominal pain and nausea. She started a new antibiotic (doxycycline) 3 days ago for her acne and has been feeling “icky” ever since.

Ask Ms. Chevy more OLDCARTS about her symptoms.

 

Physical Exam (objective)

Vital Signs: Oral Temp 36.5 C, HR 98 BPM, RR 18, and BP 120/82 mm Hg. SpO2 98%. 

Inspection: Abdomen distended-. Document rest of inspection as a normal or expected findings. 

Auscultation: Bowel sounds hyperactive in all four quadrants. Document rest of auscultation exam as normal or expected findings

Palpation: Abdomen firm and slightly tender in all quadrants. Other palpation documentation should reflect expected or normal findings

 

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