NRNP-6531-WEEK-7 IHIMAN=Ihuman
CASE-STUDY-EVITA-ALONSO ,48YRS
OLD FEMALE HISPANIC AMERICAN
FEMALE CC= Abdominal-pain 3 Different
version
]
CC:
... [Show More] 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. Alonso 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 gnaw 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
Surh type/when/why/complications
Tubal ligation
Immunizations: States her immunizations are
current. She had the influenza vaccine this
season and still got the flu.
Fahm
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
TX
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 Hex
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hex/sexual hex
and concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hex 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.
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.
Derma: 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 [Show Less]