INHUMAN CASE STUDY EVITA ALONSO, 48YRS OLD FEMALE
HISPANIC AMERICAN FEMALE CC: ABDOMINAL PAIN 3 DIFFERENT
VERSIONS EXPERT CERTIFIED 100%
PAGE 1
, VERSION A
CC: abdominal pain HPI:
48-year-old Hispanic female. A&O x 4. Appears well developed, well nourished. Patient reports having intermittent upper right quadrant abdominal
pain that started 2 weeks ago. Has progressively gotten worse over the last 2 days and is now constant. Describes it as a constant deep abdominal
cramping, gnawing, and achiness under right ribs deep inside which radiates with pain in the right shoulder. Severity 4/10. Reports nausea and
vomiting and fever for 2 days. Reports history of acid reflux. Use of antacids and Ibuprofen provides no relief for her current abdominal pain. Patient
reports pain is brought on by eating food. Patient reports not drinking adequate amount of fluid because of the vomiting. History of abdominal pain
a few times over the last year that has always gone away on its own, but never this severe. Patient denies dysphagia, chest pain, SOB, blood in
emesis, blood in stool or blood in urine. Denies any one event or activity associated with the onset of her abdominal pain.
Location: Abdomen Onset: 2 weeks ago
Character: constant cramping, gnawing, achiness in upper right abdomen under ribs Associated signs and symptoms: nausea, vomiting, fever,
radiating pain to right shoulder. Timing: After eating meals
Exacerbating/relieving factors: Eating food makes it worse. No relieving factors, antacids do not work.
Severity: 4/10 today. Starts as a 2-3/10 and increases up to 6-7/10 on other days. Allergies: NKDA Medications:
• Ibuprofen 400mg TID prn pain
• OTC antacids prn acid reflux
PMH:
• Occasional acid reflux, heartburn, relieved with OTC antacids
• Occasional knee pain and stiffness, with frequent use of Ibuprofen prn
Hospitalizations: No open surgeries. Childbirth. G3P3. Bilateral tubal ligation with last delivery. Preventative Health:
• CA Screening modalities for gender/age: Regular annual health screening 4 months ago, yearly gynecologic exam last year.
• Fitness: walks daily, light weight training 3 x week at the gym.
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, • Nutrition: Mediterranean diet, avoids fast food.
• Stress reduction: enjoys family time. Social history:
• Marital status/Support system: Married x 18 years. Parents live 3 hours away.
• Children: 3 children, doing well in school, and physically active.
• Housing: Off base private housing
• Occupation: Army Lieutenant Colonel
• Substance/Alcohol use: Reports 2 glasses of wine with dinner. Has not had any alcohol for last 2 days. Denies tobacco products and illicit
drug use.
Family Medical History:
• Father: age 70, well health. History of heart disease, Peptic ulcer disease
• Mother: age 69, well health. Breast CA in remission; s/p cholecystectomy for cholelithiasis.
ROS:
General: Reports abdominal pain, radiating right shoulder pain x 2 weeks. Reports nausea and vomiting, fever x 2 days.
HEENT: Denies dysphagia
Cardiovascular: Denies heart disease, chest pain, angina. Respiratory: Denies respiratory difficulty, SOB.
Gastrointestinal: Reports upper right quadrant abdominal pain 4/10 x 2 weeks, getting worse over last 2 days. Reports nausea and vomiting x 2
days. Denies blood in emesis. Denies constipation, diarrhea, or blood in stool.
Genitourinary: Reports decreased urine output with dark colored urine. Denies blood in urine. Denies menstrual problems, or irregular menses.
Musculoskeletal: Reports radiating right shoulder pain 4/10. Neurologic: negative
Integument/Breasts: negative
Psychiatric: Reports eating Mediterranean diet. Exercising regularly. Endocrine: Reports fever x 2 days
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HISPANIC AMERICAN FEMALE CC: ABDOMINAL PAIN 3 DIFFERENT
VERSIONS EXPERT CERTIFIED 100%
PAGE 1
, VERSION A
CC: abdominal pain HPI:
48-year-old Hispanic female. A&O x 4. Appears well developed, well nourished. Patient reports having intermittent upper right quadrant abdominal
pain that started 2 weeks ago. Has progressively gotten worse over the last 2 days and is now constant. Describes it as a constant deep abdominal
cramping, gnawing, and achiness under right ribs deep inside which radiates with pain in the right shoulder. Severity 4/10. Reports nausea and
vomiting and fever for 2 days. Reports history of acid reflux. Use of antacids and Ibuprofen provides no relief for her current abdominal pain. Patient
reports pain is brought on by eating food. Patient reports not drinking adequate amount of fluid because of the vomiting. History of abdominal pain
a few times over the last year that has always gone away on its own, but never this severe. Patient denies dysphagia, chest pain, SOB, blood in
emesis, blood in stool or blood in urine. Denies any one event or activity associated with the onset of her abdominal pain.
Location: Abdomen Onset: 2 weeks ago
Character: constant cramping, gnawing, achiness in upper right abdomen under ribs Associated signs and symptoms: nausea, vomiting, fever,
radiating pain to right shoulder. Timing: After eating meals
Exacerbating/relieving factors: Eating food makes it worse. No relieving factors, antacids do not work.
Severity: 4/10 today. Starts as a 2-3/10 and increases up to 6-7/10 on other days. Allergies: NKDA Medications:
• Ibuprofen 400mg TID prn pain
• OTC antacids prn acid reflux
PMH:
• Occasional acid reflux, heartburn, relieved with OTC antacids
• Occasional knee pain and stiffness, with frequent use of Ibuprofen prn
Hospitalizations: No open surgeries. Childbirth. G3P3. Bilateral tubal ligation with last delivery. Preventative Health:
• CA Screening modalities for gender/age: Regular annual health screening 4 months ago, yearly gynecologic exam last year.
• Fitness: walks daily, light weight training 3 x week at the gym.
PAGE 2
, • Nutrition: Mediterranean diet, avoids fast food.
• Stress reduction: enjoys family time. Social history:
• Marital status/Support system: Married x 18 years. Parents live 3 hours away.
• Children: 3 children, doing well in school, and physically active.
• Housing: Off base private housing
• Occupation: Army Lieutenant Colonel
• Substance/Alcohol use: Reports 2 glasses of wine with dinner. Has not had any alcohol for last 2 days. Denies tobacco products and illicit
drug use.
Family Medical History:
• Father: age 70, well health. History of heart disease, Peptic ulcer disease
• Mother: age 69, well health. Breast CA in remission; s/p cholecystectomy for cholelithiasis.
ROS:
General: Reports abdominal pain, radiating right shoulder pain x 2 weeks. Reports nausea and vomiting, fever x 2 days.
HEENT: Denies dysphagia
Cardiovascular: Denies heart disease, chest pain, angina. Respiratory: Denies respiratory difficulty, SOB.
Gastrointestinal: Reports upper right quadrant abdominal pain 4/10 x 2 weeks, getting worse over last 2 days. Reports nausea and vomiting x 2
days. Denies blood in emesis. Denies constipation, diarrhea, or blood in stool.
Genitourinary: Reports decreased urine output with dark colored urine. Denies blood in urine. Denies menstrual problems, or irregular menses.
Musculoskeletal: Reports radiating right shoulder pain 4/10. Neurologic: negative
Integument/Breasts: negative
Psychiatric: Reports eating Mediterranean diet. Exercising regularly. Endocrine: Reports fever x 2 days
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