iHuman Case Study Evita Alonso, 48yrs Old Female Hispanic Ameri
d d d d d d d d d
can Female CC: Abdominal Pain 3 DIFFERENT VERSIONS OFTHE AN
d d d d d d d d d d
SWER EXPERT FEEDBACK (SOLUTIONS) NRNP 6531 WEEK 7 IHUMA
d d d d d d d d
N WALDEN UNIVERSITY d d
[CONTENTS : OLD- d d
CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL EXAM,EXAMS FEEDB
d d d d d d d
ACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL d
RANKING ,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
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Miss/Leading/Alternate/Concluding)
]
,CC:d48dy/odF HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
d d d d d d d
Chiefdcomplaintdisdadshortd1-
2dstatementdordworddphrasedfromdpatientdanddshoulddbedl Mrs.dAlonsodisdad48-year-
isteddind“quotes” olddfemaledpatientdwhodpresenteddtodthedclinicdwithdadprogressive,dintermittentdrigh
tdupperdquadrantdpaindfordthedpastd2dweeksdanddwhichdhasdincreaseddindseveritydindt
“Mydstomachdhasdbeendhurtingdreallydbaddoverdt hedpastd2ddays.dThedpaindradiatesdtodthedrightdshoulder.dShedalsodcomplainsdofdasso
hedpastd2dseeks” ciateddsymptomsdlikednausea,dvomiting,danorexiadsincedthedpastd2ddays.dShedhasdha
ddpreviousdrecurrentdself-
resolvingdsymptomsdoverdthedlastdonedyear.dPainduseddtodbedprecipitateddbydfastdfoo
ddbutdnotdoccursdwithdalldfoodsdanddunresponsivedwithdantacidsdanddNSAIDS.
Onset:d2dweeksdago,dwithdsymptomsdbecomingdmoreddreadfuld2ddaysdagodLocat
ion:dRightdupperdquadrantdanddoccasionallydradiateddtodthedrightdshoulderdDurati
on:dPaindhasdbeendconstantdsinceditdstarteddthisdtime;dindthedpastditdonlydlastedd1-
2ddays.
Character:d Crampydgnawydachiness
Aggravating/alleviatingdfactors:dPaindgetsdworsedwithdmealsdanddunresolvedd
withdantacidsdanddNSAIDs
Relateddsymptoms:dNausea.dVomiting,danorexiadwithdonsetdofdsymptomsd2ddaysda
go.dDeniesdanydrecentdexposuredtodotherdilldcontacts.dShedhasdhaddsimilardsympto
msdpreviously
Treatments:dHasdtrieddOTCdantacidsdanddibuprofendwithoutdrelief
Significance:d Paindstartsdwithdadscaledofd2-3danddgetsdupdtod6-
7.dShedreportsdpaindhasdkeptdherdhomedfromdwork.
PMHxdchild/adultdillness/hospitaliz SurgHx type/when/why/complications
d
ations/immunizations
Negativedfordanydchronicdillnesses.dShedhasd Tubaldligation
occasionaldheartburndanddarthritis
Frequentdepisodesdofdcommondcoldsdanddasdchildd
Nodhospitalizations,dtraumadordotherdinjuries
, Immunizations:dStatesdherdimmunizationsdared
current.dShedhaddthedinfluenzadvaccinedthisdse
asondanddstilldgotdthedflu.
FamHx SHx
Grandparentsd(ifdknown)/Parents/siblings/children Tobacco/vaping/ETOH/illicitd drugd use/occupational/environmental/relationships
Grandparents- Shedreportsdthatdsheddrinksdadglassdofdwinedwithddinnerdmostdnights;dSheddeniesda
dstatesdnodknowndhistorydFatherdisd70d years-
nydtobaccodordrecreationalddrugduse
olddanddstilldalivedanddwelld(70):dheartddisease,
dpepticdulcerddisease
Motherdisd69dyears-
olddanddalive:dbreastdcancerdindremission;dcholec
ystectomydfordcholelithiasis
ReproductivedHx Allergiesd(Food,dDrug,dEnvironmental,detc)
Female:Agedofdmenarche/menstruationdcycledduration/gr
avidadparadstatus/Childbirthdhx/sexualdhxdanddconcerns/L Nodknownddrugdallergies
MP/menopause
Breast/cervicald screeningd (ifd any)
Male:dSexualdhxdanddconcerns/issuesdwithdfertilityd(ifd
any)/Testiculardordprostatedscreeningd(ifdapplicable)d ListdofdMedications/supplementsd(prescription,dOTC,dcomplementaryd
ScreeningdfordSTI’sd(ifdapplicable) alternativedtherapies)
Pertinentdsexualdhistory:dNotdsexuallydactivedandd Antacidsdasdneededdford"heartburn"
deniesdanydsexualdconcerns Ibuprofend400dmgdthreedtimesddailydasdneededdfordkneedpaind
Multivitamins
ReviewdofdSystems:d(ROS)dUsedthisdcolumndtod FromdthedROS:dlist/highlightdthedcurrentdsymptoms/complaintsdtodgeneratedadli
documentdthedROSdbelow. stdofd“reporteddorddenied”dsymptomsdbelow:
General:dReportsdsomedweightdloss,dfever,dnightd
PertinentdpositivedROS:dReportsdsomedweightdloss,dfever,dnightdsweats,dandddif
sweats,dandddifficultydsleeping
ficultydsleeping;dRUQdabdominaldthatdworsensdwithdfooddanddpaindscaledofd2-
HEENT:dDeniesdheadaches,dchangesdindvision,
d3/10danddprogressesdtod6-7/10,d6/10.dAnorexia,dnauseadanddvomitingdatdonset.
d d d d d d d d d
can Female CC: Abdominal Pain 3 DIFFERENT VERSIONS OFTHE AN
d d d d d d d d d d
SWER EXPERT FEEDBACK (SOLUTIONS) NRNP 6531 WEEK 7 IHUMA
d d d d d d d d
N WALDEN UNIVERSITY d d
[CONTENTS : OLD- d d
CARTS for the HPI,(PMH,FH,SH as Needed),PHSICAL EXAM,EXAMS FEEDB
d d d d d d d
ACK,CASE FINDINGS,FEEDBACK,DIFFERENTIAL d
RANKING ,DIAGNOSIS,CASE PLAN, List the differential diagnoses (Must not
d d d d d d d d d
Miss/Leading/Alternate/Concluding)
]
,CC:d48dy/odF HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
d d d d d d d
Chiefdcomplaintdisdadshortd1-
2dstatementdordworddphrasedfromdpatientdanddshoulddbedl Mrs.dAlonsodisdad48-year-
isteddind“quotes” olddfemaledpatientdwhodpresenteddtodthedclinicdwithdadprogressive,dintermittentdrigh
tdupperdquadrantdpaindfordthedpastd2dweeksdanddwhichdhasdincreaseddindseveritydindt
“Mydstomachdhasdbeendhurtingdreallydbaddoverdt hedpastd2ddays.dThedpaindradiatesdtodthedrightdshoulder.dShedalsodcomplainsdofdasso
hedpastd2dseeks” ciateddsymptomsdlikednausea,dvomiting,danorexiadsincedthedpastd2ddays.dShedhasdha
ddpreviousdrecurrentdself-
resolvingdsymptomsdoverdthedlastdonedyear.dPainduseddtodbedprecipitateddbydfastdfoo
ddbutdnotdoccursdwithdalldfoodsdanddunresponsivedwithdantacidsdanddNSAIDS.
Onset:d2dweeksdago,dwithdsymptomsdbecomingdmoreddreadfuld2ddaysdagodLocat
ion:dRightdupperdquadrantdanddoccasionallydradiateddtodthedrightdshoulderdDurati
on:dPaindhasdbeendconstantdsinceditdstarteddthisdtime;dindthedpastditdonlydlastedd1-
2ddays.
Character:d Crampydgnawydachiness
Aggravating/alleviatingdfactors:dPaindgetsdworsedwithdmealsdanddunresolvedd
withdantacidsdanddNSAIDs
Relateddsymptoms:dNausea.dVomiting,danorexiadwithdonsetdofdsymptomsd2ddaysda
go.dDeniesdanydrecentdexposuredtodotherdilldcontacts.dShedhasdhaddsimilardsympto
msdpreviously
Treatments:dHasdtrieddOTCdantacidsdanddibuprofendwithoutdrelief
Significance:d Paindstartsdwithdadscaledofd2-3danddgetsdupdtod6-
7.dShedreportsdpaindhasdkeptdherdhomedfromdwork.
PMHxdchild/adultdillness/hospitaliz SurgHx type/when/why/complications
d
ations/immunizations
Negativedfordanydchronicdillnesses.dShedhasd Tubaldligation
occasionaldheartburndanddarthritis
Frequentdepisodesdofdcommondcoldsdanddasdchildd
Nodhospitalizations,dtraumadordotherdinjuries
, Immunizations:dStatesdherdimmunizationsdared
current.dShedhaddthedinfluenzadvaccinedthisdse
asondanddstilldgotdthedflu.
FamHx SHx
Grandparentsd(ifdknown)/Parents/siblings/children Tobacco/vaping/ETOH/illicitd drugd use/occupational/environmental/relationships
Grandparents- Shedreportsdthatdsheddrinksdadglassdofdwinedwithddinnerdmostdnights;dSheddeniesda
dstatesdnodknowndhistorydFatherdisd70d years-
nydtobaccodordrecreationalddrugduse
olddanddstilldalivedanddwelld(70):dheartddisease,
dpepticdulcerddisease
Motherdisd69dyears-
olddanddalive:dbreastdcancerdindremission;dcholec
ystectomydfordcholelithiasis
ReproductivedHx Allergiesd(Food,dDrug,dEnvironmental,detc)
Female:Agedofdmenarche/menstruationdcycledduration/gr
avidadparadstatus/Childbirthdhx/sexualdhxdanddconcerns/L Nodknownddrugdallergies
MP/menopause
Breast/cervicald screeningd (ifd any)
Male:dSexualdhxdanddconcerns/issuesdwithdfertilityd(ifd
any)/Testiculardordprostatedscreeningd(ifdapplicable)d ListdofdMedications/supplementsd(prescription,dOTC,dcomplementaryd
ScreeningdfordSTI’sd(ifdapplicable) alternativedtherapies)
Pertinentdsexualdhistory:dNotdsexuallydactivedandd Antacidsdasdneededdford"heartburn"
deniesdanydsexualdconcerns Ibuprofend400dmgdthreedtimesddailydasdneededdfordkneedpaind
Multivitamins
ReviewdofdSystems:d(ROS)dUsedthisdcolumndtod FromdthedROS:dlist/highlightdthedcurrentdsymptoms/complaintsdtodgeneratedadli
documentdthedROSdbelow. stdofd“reporteddorddenied”dsymptomsdbelow:
General:dReportsdsomedweightdloss,dfever,dnightd
PertinentdpositivedROS:dReportsdsomedweightdloss,dfever,dnightdsweats,dandddif
sweats,dandddifficultydsleeping
ficultydsleeping;dRUQdabdominaldthatdworsensdwithdfooddanddpaindscaledofd2-
HEENT:dDeniesdheadaches,dchangesdindvision,
d3/10danddprogressesdtod6-7/10,d6/10.dAnorexia,dnauseadanddvomitingdatdonset.
