NRNP-6531-WEEK-7 IHIMAN=Ihuman
CASE-STUDY-EVITA-ALONSO ,48YRS
OLD FEMALE HISPANIC AMERICAN
FEMALE CC= Abdominal-pain 3 Different
version
]
,CC:104810y/o10F HPI:10pertinent10s/s;10+/-10ROS/prior10episodes/recent10travel/ill10contacts
Chief1 0 complaint1 0 is1 0 a1 0 short1 0 1-
21 0 statement1 0 or1 0 word1 0 phrase10from10patient10and10s Mrs.10Alonso10is10a1048-year-
hould10be10listed10in10“quotes” old10female10patient10who10presented10to10the10clinic10with10a10progressive,10inte
rmittent10right10upper10quadrant10pain10for10the10past10210weeks10and10which10ha
“My10stomach10has10been10hurting10really10ba s10increased10in10severity10in10the10past10210days.10The10pain10radiates10to10the10r
d10over10the10past10210seeks” ight10shoulder.10She10also10complains10of10associated10symptoms10like10nausea,1
0vomiting,10anorexia10since10the10past10210days.10She10has10had10previous10recurr
ent10self-
resolving10symptoms10over10the10last10one10year.10Pain10used10to10be10precipitate
d10by10fast10food10but10not10occurs10with10all10foods10and10unresponsive10with10an
tacids10and10NSAIDS.
Onset:10210weeks10ago,10with10symptoms10becoming10more10dreadful10210days10a
go10Location:10Right10upper10quadrant10and10occasionally10radiated10to10the10righ
t10shoulder10Duration:10Pain10has10been10constant10since10it10started10this10time;10i
n10the10past10it10only10lasted101-210days.
Character:10Crampy10gnaw10achiness
Aggravating/alleviating10factors:10Pain10gets10worse10with10meals10and10unresolv
ed10with10antacids10and10NSAIDs
Related10symptoms:10Nausea.10Vomiting,10anorexia10with10onset10of10symptom
s10210days10ago.10Denies10any10recent10exposure10to10other10ill10contacts.10She10h
as10had10similar10symptoms10previously
Treatments:10Has10tried10OTC10antacids10and10ibuprofen10without10relief10Sig
nificance:10Pain10starts10with10a10scale10of102-310and10gets10up10to106-
7.10She10reports10pain10has10kept10her10home10from10work.
PMHx10child/adult10illness/hospitalizations/immuniza Surh10type/when/why/complications
tions
Negative1 0 for1 0 any1 0 chronic1 0 illnesses.1 0 She1 Tubal10ligation
0 has10occasional10heartburn10and10arthritis
Frequent10episodes10of10common10colds10and10a
s10child10No10hospitalizations,10trauma10or10other
10injuries
, Immunizations:10States10her10immunizations1
0are10current.10She10had10the10influenza10vacc
ine10this10season10and10still10got10the10flu.
Fahm TX
Grandparents10(if10known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit10drug10use/occupational/environmental/relationships
Grandparents- She10reports10that10she10drinks10a10glass10of10wine10with10dinner10most10night
10states10no10known10history10Father10is10701
s;10She10denies10any10tobacco10or10recreational10drug10use
0years-
old10and10still10alive10and10well10(70):10heart1
0disease,10peptic10ulcer10disease
Mother10is106910years-
old10and10alive:10breast10cancer10in10remission;10c
holecystectomy10for10cholelithiasis
Reproductive10Hex Allergies10(Food,10Drug,10Environmental,10etc.)
Female:10Age10of10menarche/menstruation10cycle10d
uration/gravida10para10status/Childbirth10hex/sexual1 No10known10drug10allergies
0hex10and10concerns/LMP/menopause
Breast/cervical10screening10(if10any)
Male:10Sexual10hex10and10concerns/issues10with10
fertility10(if10any)/Testicular10or10prostate10screen List of Medications/supplements (prescription, OTC,
ing10(if10applicable)10Screening10for10STI’s10(if10ap complementary10alternative10therapies)
plicable)
Antacids10as10needed10for10"heartburn"
Pertinent10sexual10history:10Not10sexually10activ Ibuprofen1040010mg10three10times10daily10as10needed10for10
e10and10denies10any10sexual10concerns knee10pain10Multivitamins
Review10of10Systems:10(ROS)10Use10this10colu From10the10ROS:10list/highlight10the10current10symptoms/complaints10to10ge
mn10to10document10the10ROS10below. nerate10a10list10of10“reported10or10denied”10symptoms10below:
General:10Reports10some10 weight10loss,10fever,
10night10sweats,10and10difficulty10sleeping
Pertinent10positive10ROS:10Reports10some10weight10loss,10fever,10night10swea
HEENT:10Denies10headaches,10changes10in10visi ts,10and10difficulty10sleeping;10RUQ10abdominal10that10worsens10with10food10a
on, nd10pain10scale10of102-103/1010and10progresses10to106-
7/10,106/10.10Anorexia,10nausea10and10vomiting10at10onset.
CASE-STUDY-EVITA-ALONSO ,48YRS
OLD FEMALE HISPANIC AMERICAN
FEMALE CC= Abdominal-pain 3 Different
version
]
,CC:104810y/o10F HPI:10pertinent10s/s;10+/-10ROS/prior10episodes/recent10travel/ill10contacts
Chief1 0 complaint1 0 is1 0 a1 0 short1 0 1-
21 0 statement1 0 or1 0 word1 0 phrase10from10patient10and10s Mrs.10Alonso10is10a1048-year-
hould10be10listed10in10“quotes” old10female10patient10who10presented10to10the10clinic10with10a10progressive,10inte
rmittent10right10upper10quadrant10pain10for10the10past10210weeks10and10which10ha
“My10stomach10has10been10hurting10really10ba s10increased10in10severity10in10the10past10210days.10The10pain10radiates10to10the10r
d10over10the10past10210seeks” ight10shoulder.10She10also10complains10of10associated10symptoms10like10nausea,1
0vomiting,10anorexia10since10the10past10210days.10She10has10had10previous10recurr
ent10self-
resolving10symptoms10over10the10last10one10year.10Pain10used10to10be10precipitate
d10by10fast10food10but10not10occurs10with10all10foods10and10unresponsive10with10an
tacids10and10NSAIDS.
Onset:10210weeks10ago,10with10symptoms10becoming10more10dreadful10210days10a
go10Location:10Right10upper10quadrant10and10occasionally10radiated10to10the10righ
t10shoulder10Duration:10Pain10has10been10constant10since10it10started10this10time;10i
n10the10past10it10only10lasted101-210days.
Character:10Crampy10gnaw10achiness
Aggravating/alleviating10factors:10Pain10gets10worse10with10meals10and10unresolv
ed10with10antacids10and10NSAIDs
Related10symptoms:10Nausea.10Vomiting,10anorexia10with10onset10of10symptom
s10210days10ago.10Denies10any10recent10exposure10to10other10ill10contacts.10She10h
as10had10similar10symptoms10previously
Treatments:10Has10tried10OTC10antacids10and10ibuprofen10without10relief10Sig
nificance:10Pain10starts10with10a10scale10of102-310and10gets10up10to106-
7.10She10reports10pain10has10kept10her10home10from10work.
PMHx10child/adult10illness/hospitalizations/immuniza Surh10type/when/why/complications
tions
Negative1 0 for1 0 any1 0 chronic1 0 illnesses.1 0 She1 Tubal10ligation
0 has10occasional10heartburn10and10arthritis
Frequent10episodes10of10common10colds10and10a
s10child10No10hospitalizations,10trauma10or10other
10injuries
, Immunizations:10States10her10immunizations1
0are10current.10She10had10the10influenza10vacc
ine10this10season10and10still10got10the10flu.
Fahm TX
Grandparents10(if10known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit10drug10use/occupational/environmental/relationships
Grandparents- She10reports10that10she10drinks10a10glass10of10wine10with10dinner10most10night
10states10no10known10history10Father10is10701
s;10She10denies10any10tobacco10or10recreational10drug10use
0years-
old10and10still10alive10and10well10(70):10heart1
0disease,10peptic10ulcer10disease
Mother10is106910years-
old10and10alive:10breast10cancer10in10remission;10c
holecystectomy10for10cholelithiasis
Reproductive10Hex Allergies10(Food,10Drug,10Environmental,10etc.)
Female:10Age10of10menarche/menstruation10cycle10d
uration/gravida10para10status/Childbirth10hex/sexual1 No10known10drug10allergies
0hex10and10concerns/LMP/menopause
Breast/cervical10screening10(if10any)
Male:10Sexual10hex10and10concerns/issues10with10
fertility10(if10any)/Testicular10or10prostate10screen List of Medications/supplements (prescription, OTC,
ing10(if10applicable)10Screening10for10STI’s10(if10ap complementary10alternative10therapies)
plicable)
Antacids10as10needed10for10"heartburn"
Pertinent10sexual10history:10Not10sexually10activ Ibuprofen1040010mg10three10times10daily10as10needed10for10
e10and10denies10any10sexual10concerns knee10pain10Multivitamins
Review10of10Systems:10(ROS)10Use10this10colu From10the10ROS:10list/highlight10the10current10symptoms/complaints10to10ge
mn10to10document10the10ROS10below. nerate10a10list10of10“reported10or10denied”10symptoms10below:
General:10Reports10some10 weight10loss,10fever,
10night10sweats,10and10difficulty10sleeping
Pertinent10positive10ROS:10Reports10some10weight10loss,10fever,10night10swea
HEENT:10Denies10headaches,10changes10in10visi ts,10and10difficulty10sleeping;10RUQ10abdominal10that10worsens10with10food10a
on, nd10pain10scale10of102-103/1010and10progresses10to106-
7/10,106/10.10Anorexia,10nausea10and10vomiting10at10onset.
