Tina Jones GI documentation|My essay solution

Posted: March 3rd, 2023

Tina Jones – Gastrointestinal

Documentation / Electronic Health Record

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Tina Jones presents with complaints of abdominal pain and bloating for the past three days. She describes the pain as a dull ache located in the lower abdomen. The pain is constant and is not relieved by rest or changes in position. She reports feeling nauseous but denies vomiting. Tina also reports experiencing occasional heartburn and difficulty swallowing. Upon examination, the patient appears uncomfortable and is guarding her abdomen. Vital signs are within normal limits. Abdominal exam reveals tenderness upon palpation in the lower quadrants with no rebound tenderness or rigidity. Bowel sounds are present in all four quadrants. The remainder of the physical exam is unremarkable.

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