,Patient Information
Name: Sophia Martinez
Age: 17 years old
Gender: Female
Setting: Outpatient Primary Care Clinic
Chief Complaint: “My stomach has been hurting, and I feel
nauseous.”
Reason for Encounter: Abdominal pain
History of Present Illness (HPI)Narrative: Sophia Martinez, a 17-year-
old Hispanic female, presents to the primary care clinic with a 4-day
history of intermittent, crampy abdominal pain and nausea. She
describes the pain as diffuse, centered in the lower abdomen
bilaterally, rating it 5–6/10 in severity. The pain worsens after meals,
particularly fast food, and is mildly relieved by rest or over-the-counter
antacids (calcium carbonate, taken twice with minimal effect). Sophia
reports nausea occurring 2–3 times daily, worse post-meals, without
vomiting. She experienced one episode of loose stool 2 days ago but
denies diarrhea, constipation, bloody stools, or melena. She notes mild
fatigue and bloating but denies fever, chills, weight loss, or night
sweats. Her last menstrual period ended 6 days ago, and she denies
sexual activity. The pain feels distinct from her usual mild menstrual
cramps, which resolve with ibuprofen.Sophia has no significant medical
history or prior gastrointestinal issues. She takes ibuprofen 400 mg PRN
for menstrual cramps but has avoided it due to nausea. Her diet
includes frequent fast food (3–4 times/week) due to a busy high school
schedule, and she reports stress from academics and volleyball team
, commitments. She denies alcohol, tobacco, or recreational drug use.
Her family history includes a mother with irritable bowel syndrome
(IBS). Sophia is concerned about missing school and volleyball practice,
as the pain and nausea disrupt her focus, and she worries about a
serious condition like appendicitis or an infection.Explanation: The HPI
is critical for adolescent abdominal pain to differentiate benign causes
(e.g., viral gastroenteritis, IBS) from urgent conditions (e.g.,
appendicitis, ectopic pregnancy). Sophia’s crampy, diffuse pain, nausea,
bloating, and single loose stool suggest a mild gastrointestinal etiology,
likely viral gastroenteritis, possibly exacerbated by diet and stress. The
absence of fever, bloody stools, or peritoneal signs lowers suspicion for
appendicitis or inflammatory bowel disease (IBD). Her denial of sexual
activity reduces pregnancy concerns, though testing is warranted due
to her age. Stress and academic pressures highlight the need for
patient-centered care to address psychosocial factors, ensuring
adherence and reducing anxiety, per American Academy of Family
Physicians (AAFP) guidelines.
Past Medical HistoryMedical History: No chronic illnesses or prior
gastrointestinal disorders. Sophia experiences occasional menstrual
cramps, managed with ibuprofen. No history of allergies, asthma,
diabetes, or hospitalizations.Surgical History: None
reported.Medications:
Ibuprofen 400 mg orally PRN for menstrual cramps (last dose 1
week ago).
Calcium carbonate (Tums) PRN for recent abdominal discomfort
(taken twice, minimal relief).
Name: Sophia Martinez
Age: 17 years old
Gender: Female
Setting: Outpatient Primary Care Clinic
Chief Complaint: “My stomach has been hurting, and I feel
nauseous.”
Reason for Encounter: Abdominal pain
History of Present Illness (HPI)Narrative: Sophia Martinez, a 17-year-
old Hispanic female, presents to the primary care clinic with a 4-day
history of intermittent, crampy abdominal pain and nausea. She
describes the pain as diffuse, centered in the lower abdomen
bilaterally, rating it 5–6/10 in severity. The pain worsens after meals,
particularly fast food, and is mildly relieved by rest or over-the-counter
antacids (calcium carbonate, taken twice with minimal effect). Sophia
reports nausea occurring 2–3 times daily, worse post-meals, without
vomiting. She experienced one episode of loose stool 2 days ago but
denies diarrhea, constipation, bloody stools, or melena. She notes mild
fatigue and bloating but denies fever, chills, weight loss, or night
sweats. Her last menstrual period ended 6 days ago, and she denies
sexual activity. The pain feels distinct from her usual mild menstrual
cramps, which resolve with ibuprofen.Sophia has no significant medical
history or prior gastrointestinal issues. She takes ibuprofen 400 mg PRN
for menstrual cramps but has avoided it due to nausea. Her diet
includes frequent fast food (3–4 times/week) due to a busy high school
schedule, and she reports stress from academics and volleyball team
, commitments. She denies alcohol, tobacco, or recreational drug use.
Her family history includes a mother with irritable bowel syndrome
(IBS). Sophia is concerned about missing school and volleyball practice,
as the pain and nausea disrupt her focus, and she worries about a
serious condition like appendicitis or an infection.Explanation: The HPI
is critical for adolescent abdominal pain to differentiate benign causes
(e.g., viral gastroenteritis, IBS) from urgent conditions (e.g.,
appendicitis, ectopic pregnancy). Sophia’s crampy, diffuse pain, nausea,
bloating, and single loose stool suggest a mild gastrointestinal etiology,
likely viral gastroenteritis, possibly exacerbated by diet and stress. The
absence of fever, bloody stools, or peritoneal signs lowers suspicion for
appendicitis or inflammatory bowel disease (IBD). Her denial of sexual
activity reduces pregnancy concerns, though testing is warranted due
to her age. Stress and academic pressures highlight the need for
patient-centered care to address psychosocial factors, ensuring
adherence and reducing anxiety, per American Academy of Family
Physicians (AAFP) guidelines.
Past Medical HistoryMedical History: No chronic illnesses or prior
gastrointestinal disorders. Sophia experiences occasional menstrual
cramps, managed with ibuprofen. No history of allergies, asthma,
diabetes, or hospitalizations.Surgical History: None
reported.Medications:
Ibuprofen 400 mg orally PRN for menstrual cramps (last dose 1
week ago).
Calcium carbonate (Tums) PRN for recent abdominal discomfort
(taken twice, minimal relief).
