HCS.214___Week_4___Gastrointestinal_System.docx Week 4 Assignment Gastrointestinal Sys

HCS.214___Week_4___Gastrointestinal_System.docx    Week 4 Assignment “Gastrointestinal System  University of Phoenix  HCS/214    Gastrointestinal System “ Analyzing a Progress Note  Part 1  Using the following progress note, define the highlighted terms within the chart provided.    This patient was assessed by an urgent care physician.  Progress Note:  40 y.o. female presents with a 3-day history of pain when swallowing and nausea. The patient complains of acid reflux, vomiting, and diarrhea with fever. She feels week and dehydrated. Patient notes having this before one year prior. She had a colonoscopy and endoscopy at the time and was diagnosed with esophagitis along with GERD. She denies pain in the abdomen.  Past medical history: Diverticulosis, GERD, Cholecystitis in 2011.  Meds: Nexium 20mg every day  Allergies: Sulfa, PCN  Assessment: Vital Signs: T 101 degrees, P 110, R 18, B/P 144/92, occult blood test negative.  GEN: Appear to be in acute distress, acute anemia secondary to upper GI bleeding with Melena with dropping hemoglobin from 11 to 8.  Impression: Melena secondary to ulcerative esophagitis. Diverticulosis with bleed.  Discussed with patient and planning transfer to University Hospital for direct admission.   C. Bolling, CNP  *Do not forget to include the sources for your definitions.