IHUMAN Case # 4
Perpetual Anita Aseme
IHUMAN CASE # 4: GI Evita Alfonso
NURS5342
Advanced Health Assessment
LaMicha Hogan, APRN, MSN FNP-BC
Molly
... [Show More] Toon, DNP, APRN, CPNP-PC Date
March 21, 2021
Case: Evita Alfonso
Date: March 21, 2021
CC: 48 y/o F
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes”
“My stomach has been hurting really bad over
the past 2 seeks”
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Mrs. Alfonso is a 48-year-old female patient who presented to the clinic with a
progressive, intermittent right upper quadrant pain for the past 2 weeks and
which has increased in severity in the past 2 days. The pain radiates to the right
shoulder. She also complains of associated symptoms like nausea, vomiting,
anorexia since the past 2 days. She has had previous recurrent self-resolving
symptoms over the last one year. Pain used to be precipitated by fast food but not
occurs with all foods and unresponsive with antacids and NSAIDS.
Onset: 2 weeks ago, with symptoms becoming more dreadful 2 days ago
Location: Right upper quadrant and occasionally radiated to the right shoulder
Duration: Pain has been constant since it started this time; in the past it only
lasted 1-2 days.
Character: Crampy gnawy achiness
Aggravating/alleviating factors: Pain gets worse with meals and unresolved
with antacids and NSAIDs
Related symptoms: Nausea. Vomiting, anorexia with onset of symptoms 2 days
ago. Denies any recent exposure to other ill contacts. She has had similar
symptoms previously
Treatments: Has tried OTC antacids and ibuprofen without relief
Significance: Pain starts with a scale of 2-3 and gets up to 6-7. She reports pain
has kept her home from work.
PMHx child/adult
illness/hospitalizations/immunizations
Negative for any chronic illnesses. She has
occasional heartburn and arthritis
Frequent episodes of common colds and as child
No hospitalizations, trauma or other injuries
SurgHx type/when/why/complications
Tubal ligation
Case: Evita Alfonso
Date: March 21, 2021
Immunizations: States her immunizations are
current. She had the influenza vaccine this
season and still got the flu.
FamHx
Grandparents (if known)/Parents/siblings/children
Grandparents- states no known history
Father is 70 years-old and still alive and well
(70): heart disease, peptic ulcer disease
Mother is 69 years-old and alive: breast cancer
in remission; cholecystectomy for cholelithiasis
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
She reports that she drinks a glass of wine with dinner most nights; She denies
any tobacco or recreational drug use
Reproductive Hx
Female:Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
Pertinent sexual history: Not sexually active and
denies any sexual concerns
Allergies (Food, Drug, Environmental, etc)
No known drug allergies
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Antacids as needed for "heartburn"
Ibuprofen 400 mg three times daily as needed for knee pain
Multivitamins
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Reports some weight loss, fever, night
sweats, and difficulty sleeping
HEENT: Denies headaches, changes in vision,
From the ROS: list/highlight the current symptoms/complaints to generate a
list of “reported or denied” symptoms below:
Pertinent positive ROS: Reports some weight loss, fever, night sweats, and
difficulty sleeping; RUQ abdominal that worsens with food and pain scale of 2-
3/10 and progresses to 6-7/10, 6/10. Anorexia, nausea and vomiting at onset.
Case: Evita Alfonso
Date: March 21, 2021
hearing, pain in ears o sinuses, denies nasal
drainage, denies sore throat or difficulty
swallowing.
Neck/Thyroid: Denies any pain or swelling.
Pulmonary: Denies SOB, cough, wheezing, or
pain on deep breathing
CV: Denies chest pain, palpitations, edema, or
syncopal episodes.
GI: Report’s nausea vomiting and anorexia.
Denies diarrhea or constipations. RUQ
abdominal pain.
GU: Denies dysuria or difficulty urinating.
MS: Denies muscle or joint pain or swelling
Heme: No complaints of bruising or frequent
epistaxis
Lymph: No complaint of cervical
lymphadenopathy.
Endocrine: No complaint polyuria, polydipsia,
polyphagia, or heat/cold intolerance.
Derm: Denies unusual moles, rashes, lesions.
Neuro: Denies dizziness, seizures or headaches
Psych: No complaints of sadness, hopelessness,
or panic attacks.
Pertinent negative ROS: no recent illness, denies headaches denies constipation
and diarrhea, no painful urination, no myalgias or recent trauma; Negative for
hip joint deformities or pain.
Physical Exam: (PE) Use this column to
document the PE below.
Vitals Temperature: 100.0 F (oral)
Pulse: 92 bpm - regular
Blood pressure: 136/76 mmHg - supine/sitting
Blood pressure: 126/70 mmHg - upon standing
Respiratory rate: 16 bpm
From the PE: list/highlight the presence or absence of objective findings to
generate a list of pertinent “(+) or (-)” symptoms below:
Pertinent (+) PE findings: Elevated b/p, overweight, low grade fever; Scleral
icterus; tender to palpation RUQ with voluntary guarding, positive murphy sign,
and discomfort with right flank percussion
Case: Evita Alfonso
Date: March 21, 2021
SpO2: 98% on room air
Height: 5' 6" (168.0 cm)
Weight: 170 lbs. (77.0 kg) (BMI 27.4)
General: Middle aged woman with abdominal
pain
HEENT: Scleral icterus, oral mucosa moist
No cervical lymphadenopathy, no sublingual
jaundice
Neck: Supple, normal ROM, no pain with
ROM. Negative for cervical lymphadenopathy.
Pulm: Lungs are clear to auscultation
anterior/posterior bilaterally. No cough or
wheezes.
CV: HR 92, Normal heart rate and rhythm
GI: BS normal X 4; Soft, tender to palpation of
RUQ with voluntary guarding, positive murphy
sign, and discomfort with right flank percussion.
GU: No visible or palpable inguinal hernias.
Normal pelvic exam, No masses or tenderness
MS: Normal bulk and tone
Derm: Skin warm, dry. Hair and nails normal.
Skin color appropriate for ethnicity. Skin around
RUQ is normal without redness or induration.
No pallor, jaundice, rash, or lesions
Normal skin turgor
Neuro: Negative exam
Psych: Appropriate speech, judgment,
cooperative.
Pertinent (-) PE findings: Bowel sounds normal in all 4 quadrants, Posterior
pharynx non erythematous, Negative for visible or palpable inguinal hernias,
Skin around RUQ is normal without redness or induration. no sublingual
jaundice. [Show Less]