iHuman Case Study Evita Alonso, 48yrs Old Female Hispanic Americ
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an Female CC: Abdominal Pain 3 DIFFERENT VERSIONS OFTHE ANS
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WER EXPERT FEEDBACK (SOLUTIONS) NRNP 6531 WEEK 7 IHUMAN
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WALDEN UNIVERSITY g
[CONTENTS : OLD- g g
CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL EXAM,EXAMS FEEDB
g g g g g g g
ACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL
g
RANKING ,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
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Miss/Leading/Alternate/Concluding)
]
,CC:g48gy/ogF HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
g g g g g g g
Chiefgcomplaintgisgagshortg1-
2gstatementgorgwordgphrasegfromgpatientgandgshouldgbegl Mrs.gAlonsogisgag48-year-
istedging“quotes” oldgfemalegpatientgwhogpresentedgtogthegclinicgwithgagprogressive,gintermittentgrigh
tguppergquadrantgpaingforgthegpastg2gweeksgandgwhichghasgincreasedgingseveritygingt
“Mygstomachghasgbeenghurtinggreallygbadgovergt hegpastg2gdays.gThegpaingradiatesgtogthegrightgshoulder.gShegalsogcomplainsgofgasso
hegpastg2gseeks” ciatedgsymptomsglikegnausea,gvomiting,ganorexiagsincegthegpastg2gdays.gSheghasgha
dgpreviousgrecurrentgself-
resolvinggsymptomsgovergtheglastgonegyear.gPaingusedgtogbegprecipitatedgbygfastgfoo
dgbutgnotgoccursgwithgallgfoodsgandgunresponsivegwithgantacidsgandgNSAIDS.
Onset:g2gweeksgago,gwithgsymptomsgbecominggmoregdreadfulg2gdaysgagogLocat
ion:gRightguppergquadrantgandgoccasionallygradiatedgtogthegrightgshouldergDurati
on:gPainghasgbeengconstantgsincegitgstartedgthisgtime;gingthegpastgitgonlyglastedg1-
2gdays.
Character:g Crampyggnawygachiness
Aggravating/alleviatinggfactors:gPainggetsgworsegwithgmealsgandgunresolvedg
withgantacidsgandgNSAIDs
Relatedgsymptoms:gNausea.gVomiting,ganorexiagwithgonsetgofgsymptomsg2gdaysga
go.gDeniesganygrecentgexposuregtogothergillgcontacts.gSheghasghadgsimilargsympto
msgpreviously
Treatments:gHasgtriedgOTCgantacidsgandgibuprofengwithoutgrelief
Significance:g Paingstartsgwithgagscalegofg2-3gandggetsgupgtog6-
7.gShegreportsgpainghasgkeptgherghomegfromgwork.
PMHxgchild/adultgillness/hospitaliz SurgHx type/when/why/complications
g
ations/immunizations
Negativegforganygchronicgillnesses.gSheghasg Tubalgligation
occasionalgheartburngandgarthritis
Frequentgepisodesgofgcommongcoldsgandgasgchildg
Noghospitalizations,gtraumagorgotherginjuries
, Immunizations:gStatesghergimmunizationsgareg
current.gSheghadgtheginfluenzagvaccinegthisgse
asongandgstillggotgthegflu.
FamHx SHx
Grandparentsg(ifgknown)/Parents/siblings/children Tobacco/vaping/ETOH/illicitg drugg use/occupational/environmental/relationships
Grandparents- Shegreportsgthatgshegdrinksgagglassgofgwinegwithgdinnergmostgnights;gShegdeniesga
gstatesgnogknownghistorygFathergisg70g years-
nygtobaccogorgrecreationalgdrugguse
oldgandgstillgalivegandgwellg(70):gheartgdisease,
gpepticgulcergdisease
Mothergisg69gyears-
oldgandgalive:gbreastgcancergingremission;gcholec
ystectomygforgcholelithiasis
ReproductivegHx Allergiesg(Food,gDrug,gEnvironmental,getc)
Female:Agegofgmenarche/menstruationgcyclegduration/gr
avidagparagstatus/Childbirthghx/sexualghxgandgconcerns/L Nogknowngdruggallergies
MP/menopause
Breast/cervicalg screeningg (ifg any)
Male:gSexualghxgandgconcerns/issuesgwithgfertilityg(ifg
any)/Testiculargorgprostategscreeningg(ifgapplicable)g ListgofgMedications/supplementsg(prescription,gOTC,gcomplementaryg
ScreeninggforgSTI’sg(ifgapplicable) alternativegtherapies)
Pertinentgsexualghistory:gNotgsexuallygactivegandg Antacidsgasgneededgforg"heartburn"
deniesganygsexualgconcerns Ibuprofeng400gmggthreegtimesgdailygasgneededgforgkneegpaing
Multivitamins
ReviewgofgSystems:g(ROS)gUsegthisgcolumngtog FromgthegROS:glist/highlightgthegcurrentgsymptoms/complaintsgtoggenerategaglis
documentgthegROSgbelow. tgofg“reportedgorgdenied”gsymptomsgbelow:
General:gReportsgsomegweightgloss,gfever,gnightg
PertinentgpositivegROS:gReportsgsomegweightgloss,gfever,gnightgsweats,gandgdif
sweats,gandgdifficultygsleeping
ficultygsleeping;gRUQgabdominalgthatgworsensgwithgfoodgandgpaingscalegofg2-
HEENT:gDeniesgheadaches,gchangesgingvision,
g3/10gandgprogressesgtog6-7/10,g6/10.gAnorexia,gnauseagandgvomitinggatgonset.
g g g g g g g g g
an Female CC: Abdominal Pain 3 DIFFERENT VERSIONS OFTHE ANS
g g g g g g g g g g
WER EXPERT FEEDBACK (SOLUTIONS) NRNP 6531 WEEK 7 IHUMAN
g g g g g g g g g
WALDEN UNIVERSITY g
[CONTENTS : OLD- g g
CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL EXAM,EXAMS FEEDB
g g g g g g g
ACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL
g
RANKING ,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
g g g g g g g g g
Miss/Leading/Alternate/Concluding)
]
,CC:g48gy/ogF HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
g g g g g g g
Chiefgcomplaintgisgagshortg1-
2gstatementgorgwordgphrasegfromgpatientgandgshouldgbegl Mrs.gAlonsogisgag48-year-
istedging“quotes” oldgfemalegpatientgwhogpresentedgtogthegclinicgwithgagprogressive,gintermittentgrigh
tguppergquadrantgpaingforgthegpastg2gweeksgandgwhichghasgincreasedgingseveritygingt
“Mygstomachghasgbeenghurtinggreallygbadgovergt hegpastg2gdays.gThegpaingradiatesgtogthegrightgshoulder.gShegalsogcomplainsgofgasso
hegpastg2gseeks” ciatedgsymptomsglikegnausea,gvomiting,ganorexiagsincegthegpastg2gdays.gSheghasgha
dgpreviousgrecurrentgself-
resolvinggsymptomsgovergtheglastgonegyear.gPaingusedgtogbegprecipitatedgbygfastgfoo
dgbutgnotgoccursgwithgallgfoodsgandgunresponsivegwithgantacidsgandgNSAIDS.
Onset:g2gweeksgago,gwithgsymptomsgbecominggmoregdreadfulg2gdaysgagogLocat
ion:gRightguppergquadrantgandgoccasionallygradiatedgtogthegrightgshouldergDurati
on:gPainghasgbeengconstantgsincegitgstartedgthisgtime;gingthegpastgitgonlyglastedg1-
2gdays.
Character:g Crampyggnawygachiness
Aggravating/alleviatinggfactors:gPainggetsgworsegwithgmealsgandgunresolvedg
withgantacidsgandgNSAIDs
Relatedgsymptoms:gNausea.gVomiting,ganorexiagwithgonsetgofgsymptomsg2gdaysga
go.gDeniesganygrecentgexposuregtogothergillgcontacts.gSheghasghadgsimilargsympto
msgpreviously
Treatments:gHasgtriedgOTCgantacidsgandgibuprofengwithoutgrelief
Significance:g Paingstartsgwithgagscalegofg2-3gandggetsgupgtog6-
7.gShegreportsgpainghasgkeptgherghomegfromgwork.
PMHxgchild/adultgillness/hospitaliz SurgHx type/when/why/complications
g
ations/immunizations
Negativegforganygchronicgillnesses.gSheghasg Tubalgligation
occasionalgheartburngandgarthritis
Frequentgepisodesgofgcommongcoldsgandgasgchildg
Noghospitalizations,gtraumagorgotherginjuries
, Immunizations:gStatesghergimmunizationsgareg
current.gSheghadgtheginfluenzagvaccinegthisgse
asongandgstillggotgthegflu.
FamHx SHx
Grandparentsg(ifgknown)/Parents/siblings/children Tobacco/vaping/ETOH/illicitg drugg use/occupational/environmental/relationships
Grandparents- Shegreportsgthatgshegdrinksgagglassgofgwinegwithgdinnergmostgnights;gShegdeniesga
gstatesgnogknownghistorygFathergisg70g years-
nygtobaccogorgrecreationalgdrugguse
oldgandgstillgalivegandgwellg(70):gheartgdisease,
gpepticgulcergdisease
Mothergisg69gyears-
oldgandgalive:gbreastgcancergingremission;gcholec
ystectomygforgcholelithiasis
ReproductivegHx Allergiesg(Food,gDrug,gEnvironmental,getc)
Female:Agegofgmenarche/menstruationgcyclegduration/gr
avidagparagstatus/Childbirthghx/sexualghxgandgconcerns/L Nogknowngdruggallergies
MP/menopause
Breast/cervicalg screeningg (ifg any)
Male:gSexualghxgandgconcerns/issuesgwithgfertilityg(ifg
any)/Testiculargorgprostategscreeningg(ifgapplicable)g ListgofgMedications/supplementsg(prescription,gOTC,gcomplementaryg
ScreeninggforgSTI’sg(ifgapplicable) alternativegtherapies)
Pertinentgsexualghistory:gNotgsexuallygactivegandg Antacidsgasgneededgforg"heartburn"
deniesganygsexualgconcerns Ibuprofeng400gmggthreegtimesgdailygasgneededgforgkneegpaing
Multivitamins
ReviewgofgSystems:g(ROS)gUsegthisgcolumngtog FromgthegROS:glist/highlightgthegcurrentgsymptoms/complaintsgtoggenerategaglis
documentgthegROSgbelow. tgofg“reportedgorgdenied”gsymptomsgbelow:
General:gReportsgsomegweightgloss,gfever,gnightg
PertinentgpositivegROS:gReportsgsomegweightgloss,gfever,gnightgsweats,gandgdif
sweats,gandgdifficultygsleeping
ficultygsleeping;gRUQgabdominalgthatgworsensgwithgfoodgandgpaingscalegofg2-
HEENT:gDeniesgheadaches,gchangesgingvision,
g3/10gandgprogressesgtog6-7/10,g6/10.gAnorexia,gnauseagandgvomitinggatgonset.
