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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