Female Hispanic American Female CC:
, Abdominal Pain 3 DIFFERENT
VERSIONS OF THE ANSWER
EXPERT FEEDBACK
NRNP 6531 WEEK 7 IHUMAN WALDEN
UNIVERSITY
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iHuman Case Study Evita Alonso, 48yrs Old Female Hispanic American Female CC: Abdominal Pain 3 DIFFERENT VERSIONS OF THE ANSWER EXPERT FEEDBACK NRNP 6531 WEEK 7 IHUMAN WALDEN UNIVERSITY 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 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 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. 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 TX Grandparents (if known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships Grandparents- states no known history She reports that she drinks a glass of wine with dinner most nights; She denies Father is 70 years-old and still alive and well any tobacco or recreational drug use (70): heart disease, peptic ulcer disease Mother is 69 years-old and alive: breast cancer in remission; cholecystectomy for cholelithiasis Reproductive Hex Allergies (Food, Drug, Environmental, etc.) Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hex/sexual hex No known drug allergies and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hex and concerns/issues with fertility (if any)/Testicular or prostate screening (if List of Medications/supplements (prescription, OTC, complementary applicable) Screening for STI’s (if applicable) alternative therapies) Pertinent sexual history: Not sexually active and Antacids as needed for "heartburn" denies any sexual concerns Ibuprofen 400 mg three times daily as needed for knee pain Multivitamins
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