Background info (Subjective) Ms. Chevy is a 22-year-old Caucasian female. Admitted diagnosis: Abdominal pain and nausea Past medical history:

Question 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 nauseaPast medical history: acne Medications include calcium supplement, oral contraceptive pill, new antibiotic for acneAllergies to Sulfa medicationsSubstance 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 findingsPalpation: Abdomen firm and slightly tender in all quadrants. Other palpation documentation should reflect expected or normal findings Content: Use of three sections: o Subjectiveo Objectiveo Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Health Science Science Nursing NUR 2180 Share QuestionEmailCopy link Comments (0)