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CASE STUDY OF A 15-YEARS OLD FEMALE REASON FOR
ENCOUNTER ABDOMINAL PAIN
WEEK 7 NRNP 6541 Ihuman analysis
PATIENT INFORMATION:
Patient Name: Sofia Hernandez
Age: 15 years
Gender: Female
Height: 5’ 8” (173cm)
, 2
Weight: 148.0lb (67.7kg)
History of Present Illness (HPI):
Sofia Hernandez is a 15-year-old Hispanic female who presents to the clinic with a chief
complaint of abdominal pain for the past 3 days.
• Onset: Gradual onset, started 3 days ago.
• Location: Pain started around the umbilicus but has now moved to the right
lower quadrant (RLQ).
• Duration: Constant pain throughout the day with occasional worsening.
• Characteristics: Described as sharp and cramping.
• Severity: Rates current pain as 7/10 on pain scale.
• Aggravating Factors: Worsens with movement, such as walking or coughing.
• Relieving Factors: No significant relief with over-the-counter medications
(acetaminophen).
• Associated Symptoms:
o Nausea: Yes
o Vomiting: Vomited twice yesterday (non-bloody, non-bilious)
o Fever: Reports subjective fever, recorded temperature at home 38.3°C
(100.9°F).
o Appetite: Decreased appetite over the last 2 days.
o Bowel Movements: Last bowel movement was yesterday; normal
consistency, no diarrhea or blood.
o Urinary Symptoms: Denies dysuria or urinary frequency.
• Menstrual History: Last menstrual period was 4 weeks ago; reports irregular
periods, denies being sexually active.
Review of Systems (ROS):
CASE STUDY OF A 15-YEARS OLD FEMALE REASON FOR
ENCOUNTER ABDOMINAL PAIN
WEEK 7 NRNP 6541 Ihuman analysis
PATIENT INFORMATION:
Patient Name: Sofia Hernandez
Age: 15 years
Gender: Female
Height: 5’ 8” (173cm)
, 2
Weight: 148.0lb (67.7kg)
History of Present Illness (HPI):
Sofia Hernandez is a 15-year-old Hispanic female who presents to the clinic with a chief
complaint of abdominal pain for the past 3 days.
• Onset: Gradual onset, started 3 days ago.
• Location: Pain started around the umbilicus but has now moved to the right
lower quadrant (RLQ).
• Duration: Constant pain throughout the day with occasional worsening.
• Characteristics: Described as sharp and cramping.
• Severity: Rates current pain as 7/10 on pain scale.
• Aggravating Factors: Worsens with movement, such as walking or coughing.
• Relieving Factors: No significant relief with over-the-counter medications
(acetaminophen).
• Associated Symptoms:
o Nausea: Yes
o Vomiting: Vomited twice yesterday (non-bloody, non-bilious)
o Fever: Reports subjective fever, recorded temperature at home 38.3°C
(100.9°F).
o Appetite: Decreased appetite over the last 2 days.
o Bowel Movements: Last bowel movement was yesterday; normal
consistency, no diarrhea or blood.
o Urinary Symptoms: Denies dysuria or urinary frequency.
• Menstrual History: Last menstrual period was 4 weeks ago; reports irregular
periods, denies being sexually active.
Review of Systems (ROS):
