Documentation of an Assessment of the Gastrointestinal System (Other (Not Listed) Sample)

Documentation of an Assessment of the Gastrointestinal System
Student Name
Rasmussen College
Course Name
Professor’s Name
Assignment Due Date
Documentation of an Assessment of the Gastrointestinal System
The stomach is one of the body's most sensitive systems that require quality healthcare. There are many diseases/infections related to the stomach, more specifically, the gastrointestinal system. Gastritis is one of the gastrointestinal disorders accompanied by various symptoms that affect the abdomen, oral intake, patient's constitution, and bowel movements. Checking through a patient's history helps guide the right clinical examinations and get a specific differential diagnosis.
Case study
A twenty-seven-year-old female, weighing a hundred pounds. Height 5ft 3'. She was brought in looking dehydrated and pale. Not much information was obtained from the patient's parents, who had brought her in for examination. The patient is also not a very reliable source as she is not fully conscious.
Presenting Complaint
The patient complained of having:
* Sharp abdominal pains (Epigastric pain)- possibly because of the patient's irritable bowel syndrome. Can be assessed using iliopsoas muscle, Blumberg, or obturator tests. Auscultation can also be performed for further assessment (Maryniak, 2018).
* Vomiting- Acutely, with increased intensity during morning hours.
* Nausea (associated symptoms/signs)- a possible medication side effect.
* (Abnormal stool) fresh blood in stool- Haematochezia with alight consistency.
* Weight loss could be explained by acute vomiting, nausea, and difficulty swallowing, hence eating small portions of meals (changed appetite).
* Abnormally dry mouth- especially around the corners of the mouth.
* Difficulty in swallowing.
* Anorectal pains- No history of colonoscopy procedures performed. Caused by abscess as evidenced by an abnormal soft mass surrounded by a red/pink coloration, treatable by antibiotics and dry and warm compresses or a bottle of hot water.
* Appears to have jaundice (generalized skin discoloration (yellow))- The lower part of her back and abdomen have an abnormal inconsistent color compared to the rest of the body, with lesions, bulges, and dark scars.
History of Present Illness (HPI)
The abdominal pains are in the lower abdomen, vomiting and nausea started three days ago all over sudden. The weight loss has been gradual (a total of ten pounds lost in three days). At night, the patient experiences a high burning fever. The vomiting and nausea intensify in the morning hours on a scale of 9 out of 10 (Potter, 2021). A dry mouth and difficulty in swallowing started on the second day. The patient has trouble even swallowing water and other fluids.
Background Medical History
Stable hypertension pressure levels of 120-140 78-90. Family history of chronic diseases present (asthma). Has peptic ulcers, irritable bowel syndrome, inflamed bowel disease, and liver cirrhosis. No family history of cancer, autoimmune disorders or Wilson's disease, or hemochromatosis. No allergies.
History of past procedures
The patient has had one appendectomy surgery done over a year ago with no following complications. She has not had a stoma formation in the past. She has not had any liver transplant but is scheduled to have one in six months.
Medication History
Prednisolone and mesalazine for the inflamed bowel disease. Lactulose, pantoprazole for the peptic ulcers, rifaximin for irritable bowel syndrome, ursodiol for liver cirrhosis.
Social History
The patient is a volunteer at home for the aged and a part-time Masters' student at a local University. She lives with her parents and two younger siblings. Her parents take her to all her medical appointments and procedures. She has a robust social support system. She does most of her chores without any complications, eats a healthy diet for boosting her immunity, and regularly exercises. She has a daily morning routine of walking a distance of seven miles. No recent dietary changes, but food intake has reduced due to the pain in swallowing, hence the drastic weight loss.