IHP IHUMAN CASE STUDY EVITA ALONSO (48 YRS OLD,ABDOMINAL PAIN)

IHP IHUMAN CASE STUDY
EVITA ALONSO

(48 YRS OLD,ABDOMINAL
PAIN)

,CC:104810y/o10F HPI:10pertinent10s/s;10+/-10ROS/prior10episodes/recent10travel/ill10contacts
Chief10complaint10is10a10short101-
210statement10or10word10phrase10from10patient10and1 Mrs.10Alonso10is10a1048-year-
0should10be10listed10in10“quotes” old10female10patient10who10presented10to10the10clinic10with10a10progressive,10i
ntermittent10right10upper10quadrant10pain10for10the10past10210weeks10and10whi
“My10stomach10has10been10hurting10really10ba ch10has10increased10in10severity10in10the10past10210days.10The10pain10radiates10
d10over10the10past10210seeks” to10the10right10shoulder.10She10also10complains10of10associated10symptoms10li
ke10nausea,10vomiting,10anorexia10since10the10past10210days.10She10has10had10
previous10recurrent10self-
resolving10symptoms10over10the10last10one10year.10Pain10used10to10be10precipita
ted10by10fast10food10but10not10occurs10with10all10foods10and10unresponsive10wi
th10antacids10and10NSAIDS.
Onset:10210weeks10ago,10with10symptoms10becoming10more10dreadful10210days1
0ago10Location:10Right10upper10quadrant10and10occasionally10radiated10to10the10r
ight10shoulder10Duration:10Pain10has10been10constant10since10it10started10this10t
ime;10in10the10past10it10only10lasted101-210days.
Character:1 0 Crampy10gnawy10achiness
Aggravating/alleviating10factors:10Pain10gets10worse10with10meals10and10unres
olved10with10antacids10and10NSAIDs
Related10symptoms:10Nausea.10Vomiting,10anorexia10with10onset10of10symptoms1
0210days10ago.10Denies10any10recent10exposure10to10other10ill10contacts.10She10h
as10had10similar10symptoms10previously
Treatments:10Has10tried10OTC10antacids10and10ibuprofen10without10relief
Significance:1 0 Pain10starts10with10a10scale10of102-310and10gets10up10to106-
7.10She10reports10pain10has10kept10her10home10from10work.
PMHx10child/adult10illness/hospitalizations/immuniza SurgHx10type/when/why/complications
tions
Negative10for10any10chronic10illnesses.10She10has Tubal10ligation
10occasional10heartburn10and10arthritis
Frequent10episodes10of10common10colds10and10as
10child10No10hospitalizations,10trauma10or10other
10injuries

, Immunizations:10States10her10immunizations10a
re10current.10She10had10the10influenza10vaccin
e10this10season10and10still10got10the10flu.

FamHx SHx
Grandparents10(if10known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit10 drug1 0 use/occupational/environmental/relationships

Grandparents- She10reports10that10she10drinks10a10glass10of10wine10with10dinner10most10nights;
10states10no10known10history10Father10is107 10She10denies10any10tobacco10or10recreational10drug10use

010years-
old10and10still10alive10and10well10(70):10hear
t10disease,10peptic10ulcer10disease
Mother10is106910years-
old10and10alive:10breast10cancer10in10remissio
n;10cholecystectomy10for10cholelithiasis
Reproductive10Hx Allergies10(Food,10Drug,10Environmental,10etc)
Female:Age10of10menarche/menstruation10cycle10duratio
n/gravida10para10status/Childbirth10hx/sexual10hx10and10 No10known10drug10allergies
concerns/LMP/menopause
Breast/cervical10 screening10 (if10any)
Male:10Sexual10hx10and10concerns/issues10with10f
ertility10(if10any)/Testicular10or10prostate10screen List10of10Medications/supplements10(prescription,10OTC,10compleme
ing10(if10applicable)10Screening10for10STI’s10(if1 ntary10alternative10therapies)
0applicable)
Antacids10as10needed10for10"heartburn"
Pertinent10sexual10history:10Not10sexually10active Ibuprofen1040010mg10three10times10daily10as10needed10for10knee10pain
10and10denies10any10sexual10concerns 10Multivitamins


Review10of10Systems:10(ROS)10Use10this10colu From10the10ROS:10list/highlight10the10current10symptoms/complaints10to10gen
mn10to10document10the10ROS10below. erate10a10list10of10“reported10or10denied”10symptoms10below:
General:10Reports10some10weight10loss,10fever,10
Pertinent10positive10ROS:10Reports10some10weight10loss,10fever,10night10sweat
night10sweats,10and10difficulty10sleeping
s,10and10difficulty10sleeping;10RUQ10abdominal10that10worsens10with10food10and1
HEENT:10Denies10headaches,10changes10in10visi
0pain10scale10of102-103/1010and10progresses10to106-
on,
7/10,106/10.10Anorexia,10nausea10and10vomiting10at10onset.