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WEEK 7 COMPREHENSIVE CASE STUDY OF A 15-YEARS OLD FEMALE REASON FOR ENCOUNTER
ABDOMINAL PAIN LOACATION EMERGENCY ROOM WITH FULL IMAGING AND LABORATOTY
CAPABILITIES
WALDEN UNIVERSITY
*Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and Inhuman Patients by Kaplan (2020)
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PATIENT INFORMATION:
Patient Name: Sofia Hernandez
Age: 15 years
Gender: Female
Height: 5’ 8” (173cm)
Weight: 148.0lb (67.7kg)
Ethnicity: Hispanic
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CC: 15 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement Sofia Hernandez is a 15-year-old female patient who presented to
or word phrase from patient and should the clinic with a progressive, intermittent right upper quadrant pain
be listed in “quotes” for the past 2 weeks and which has increased in severity in the past
2 days. The pain radiates to the right shoulder. She also complains
“My stomach has been hurting really of associated symptoms like nausea, vomiting, anorexia since the
bad over the past 2 seeks” past 2 days. She has had previous recurrent self-resolving symptoms
over the last one year. Pain used to be precipitated by fast food but
not occurs with all foods and unresponsive with antacids and
NSAIDS.
Onset: 2 weeks ago, with symptoms becoming more dreadful 2 days
ago Location: Right upper quadrant and occasionally radiated to the
right shoulder Duration: Pain has been constant since it started this
time; in the past it only lasted 1-2 days.
Character: Crampy gnaw achiness
Aggravating/alleviating factors: Pain gets worse with meals and
unresolved with antacids and NSAIDs
Related symptoms: Nausea. Vomiting, anorexia with onset of
symptoms 2 days ago. Denies any recent exposure to other ill
contacts. She has had similar symptoms previously
Treatments: Has tried OTC antacids and ibuprofen without relief
Significance: Pain starts with a scale of 2-3 and gets up to 6-7. She
reports pain has kept her home from work.
PMHx child/adult Surh type/when/why/complications
illness/hospitalizations/immunizati Tubal ligation
ons
Negative for any chronic illnesses. She
has occasional heartburn and arthritis
WEEK 7 COMPREHENSIVE CASE STUDY OF A 15-YEARS OLD FEMALE REASON FOR ENCOUNTER
ABDOMINAL PAIN LOACATION EMERGENCY ROOM WITH FULL IMAGING AND LABORATOTY
CAPABILITIES
WALDEN UNIVERSITY
*Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and Inhuman Patients by Kaplan (2020)
,2
PATIENT INFORMATION:
Patient Name: Sofia Hernandez
Age: 15 years
Gender: Female
Height: 5’ 8” (173cm)
Weight: 148.0lb (67.7kg)
Ethnicity: Hispanic
, 3
CC: 15 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement Sofia Hernandez is a 15-year-old female patient who presented to
or word phrase from patient and should the clinic with a progressive, intermittent right upper quadrant pain
be listed in “quotes” for the past 2 weeks and which has increased in severity in the past
2 days. The pain radiates to the right shoulder. She also complains
“My stomach has been hurting really of associated symptoms like nausea, vomiting, anorexia since the
bad over the past 2 seeks” past 2 days. She has had previous recurrent self-resolving symptoms
over the last one year. Pain used to be precipitated by fast food but
not occurs with all foods and unresponsive with antacids and
NSAIDS.
Onset: 2 weeks ago, with symptoms becoming more dreadful 2 days
ago Location: Right upper quadrant and occasionally radiated to the
right shoulder Duration: Pain has been constant since it started this
time; in the past it only lasted 1-2 days.
Character: Crampy gnaw achiness
Aggravating/alleviating factors: Pain gets worse with meals and
unresolved with antacids and NSAIDs
Related symptoms: Nausea. Vomiting, anorexia with onset of
symptoms 2 days ago. Denies any recent exposure to other ill
contacts. She has had similar symptoms previously
Treatments: Has tried OTC antacids and ibuprofen without relief
Significance: Pain starts with a scale of 2-3 and gets up to 6-7. She
reports pain has kept her home from work.
PMHx child/adult Surh type/when/why/complications
illness/hospitalizations/immunizati Tubal ligation
ons
Negative for any chronic illnesses. She
has occasional heartburn and arthritis
