• Wrong document? Swap it for free
  • Written by students who passed
  • Immediately available after payment
  • Read online or as PDF
Sell
Where do you study
Your language
Document preview thumbnail
Preview 2 out of 8 pages
Exam (elaborations)

Wk3 Soapnote.pdf

Document preview thumbnail
Preview 2 out of 8 pages

Exam of 8 pages for the course health care at health care (WK3 SOAPNOTE.pdf)

Content preview

NRNP 6531 WEEK_7 iHuman Case Study Evita Alonso - 48-
year-old Hispanic female CC: Abdominal pain COMPLETE
EXPERT FEEDBACK (ANSWERS) 2023 UPDATE

, CC: abdominal pain

HPI:
Evita Alonso 48-year-old Hispanic female. A&O x 4. Appears well developed, well nourished.
Patient reportshaving 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:

Document information

Uploaded on
May 21, 2025
Number of pages
8
Written in
2024/2025
Type
Exam (elaborations)
Contains
Questions & answers
$27.99

Wrong document? Swap it for free Within 14 days of purchase and before downloading, you can choose a different document. You can simply spend the amount again.
Written by students who passed
Immediately available after payment
Read online or as PDF

Sold
0
Followers
0
Items
252
Last sold
-



Why students choose Stuvia

Created by fellow students, verified by reviews

Quality you can trust: written by students who passed their tests and reviewed by others who've used these notes.

Didn't get what you expected? Choose another document

No worries! You can instantly pick a different document that better fits what you're looking for.

Pay as you like, start learning right away

No subscription, no commitments. Pay the way you're used to via credit card and download your PDF document instantly.

Student with book image

“Bought, downloaded, and aced it. It really can be that simple.”

Alisha Student

Working on your references?

Create accurate citations in APA, MLA and Harvard with our free citation generator.

Working on your references?

Frequently asked questions