CAMILA FRANKLIN I HUMAN CASE STUDY 48-YEAR OLD WITH FATIGUE AND IRRITABILITY WEEK
10 SCREENSHOTS 2024-2025 WITH HISTORY PHYSICAL EXAM ASSESMENT TEST RESULTS
DIAGNOSIS PLAN SAMMURY
,
,
, CC: 48 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes” Mrs. Alonso is a 48-year-old female patient who presented to the
clinic with a progressive, intermittent right upper quadrant pain for the
“My stomach has been hurting really bad past 2 weeks and which has increased in severity in the past 2 days.
over the past 2 seeks” The pain radiates to the right shoulder. She also complains of
associated symptoms like nausea, vomiting, anorexia since the 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 gnawy 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.
10 SCREENSHOTS 2024-2025 WITH HISTORY PHYSICAL EXAM ASSESMENT TEST RESULTS
DIAGNOSIS PLAN SAMMURY
,
,
, CC: 48 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes” Mrs. Alonso is a 48-year-old female patient who presented to the
clinic with a progressive, intermittent right upper quadrant pain for the
“My stomach has been hurting really bad past 2 weeks and which has increased in severity in the past 2 days.
over the past 2 seeks” The pain radiates to the right shoulder. She also complains of
associated symptoms like nausea, vomiting, anorexia since the 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 gnawy 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.
