WEEK 10 NRNP 6531 IHUMAN EVITA ALONSO

#WEEK 10 NRNP 6531 IHUMAN EVITA ALONSO

,48YRS OLD FEMALE HISPANIC AMERICAN FEMALE

CC= ABDOMINAL -PAIN JANUARY 2025 LATEST

SOURCED FROM CHAMBERLAIN UNIVERSITY EXPERTS TO ENLIGHTEN HANDLE ON

IHUMAN CASES

]

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. 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