NRNP-6531-WEEK-
7 IHIMAN=Ihuman CASE-STUDY-EVITA-
b b
ALONSO ,48YRS OLD FEMALE HISPANIC
b b b b b
AMERICAN FEMALE CC= Abdominal-
b b b
pain 3 Different version
b b b b
]
,CC:b48by/obF HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
b b b b b b b
Chiefb complaintb isb ab shortb 1-
2b statementb orb wordb phrasebfrombpatientbandbshouldbbeblis Mrs.bAlonsobisbab48-year-
tedbinb“quotes” oldbfemalebpatientbwhobpresentedbtobthebclinicbwithbabprogressive,bintermittentbrigh
tbupperbquadrantbpainbforbthebpastb2bweeksbandbwhichbhasbincreasedbinbseveritybinbt
“Mybstomachbhasbbeenbhurtingbreallybbadboverbt hebpastb2bdays.bThebpainbradiatesbtobthebrightbshoulder.bShebalsobcomplainsbofbassoc
hebpastb2bseeks” iatedbsymptomsblikebnausea,bvomiting,banorexiabsincebthebpastb2bdays.bShebhasbhadb
previousbrecurrentbself-
resolvingbsymptomsboverbtheblastbonebyear.bPainbusedbtobbebprecipitatedbbybfastbfoo
dbbutbnotboccursbwithballbfoodsbandbunresponsivebwithbantacidsbandbNSAIDS.
Onset:b2bweeksbago,bwithbsymptomsbbecomingbmorebdreadfulb2bdaysbagobLocation
:bRightbupperbquadrantbandboccasionallybradiatedbtobthebrightbshoulderbDuration:bPa
inbhasbbeenbconstantbsincebitbstartedbthisbtime;binbthebpastbitbonlyblastedb1-2bdays.
Character:bCrampybgnawbachiness
Aggravating/alleviatingbfactors:bPainbgetsbworsebwithbmealsbandbunresolvedbwithb
antacidsbandbNSAIDs
Relatedbsymptoms:bNausea.bVomiting,banorexiabwithbonsetbofbsymptomsb2bdaysb
ago.bDeniesbanybrecentbexposurebtobotherbillbcontacts.bShebhasbhadbsimilarbsympto
msbpreviously
Treatments:bHasbtriedbOTCbantacidsbandbibuprofenbwithoutbreliefbSignificance:
bPainbstarts bwithbabscalebofb2-3bandbgetsbupbtob6-
7.bShebreportsbpainbhasbkeptbherbhomebfrombwork.
PMHxbchild/adultbillness/hospitalizations/immunizatio Surh type/when/why/complications
b
ns
Negativeb forb anyb chronicb illnesses.b Sheb hasbocca Tubalbligation
sionalbheartburnbandbarthritis
Frequentbepisodesbofbcommonbcoldsbandbasbchildb
Nobhospitalizations,btraumaborbotherbinjuries
, Immunizations:bStatesbherbimmunizationsbareb
current.bShebhadbthebinfluenzabvaccinebthisbse
asonbandbstillbgotbthebflu.
Fahm TX
Grandparentsb(ifbknown)/Parents/siblings/children Tobacco/vaping/ETOH/illicitbdrugbuse/occupational/environmental/relationships
Grandparents- Shebreportsbthatbshebdrinksbabglassbofbwinebwithbdinnerbmostbnights;bShebdeniesba
bstates bnobknownbhistorybFatherbisb70byears-
nybtobaccoborbrecreationalbdrugbuse
oldbandbstillbalivebandbwellb(70):bheartbdisease,
bpepticbulcerbdisease
Motherbisb69byears-
oldbandbalive:bbreastbcancerbinbremission;bcholecys
tectomybforbcholelithiasis
ReproductivebHex Allergiesb(Food,bDrug,bEnvironmental,betc.)
Female:bAgebofbmenarche/menstruationbcyclebduration/
gravidabparabstatus/Childbirthbhex/sexualbhexbandbconc Nobknownbdrugballergies
erns/LMP/menopause
Breast/cervicalbscreeningb(ifbany)
Male:bSexualbhexbandbconcerns/issuesbwithbfertilityb(
ifbany)/Testicularborbprostatebscreeningb(ifbapplicabl List of Medications/supplements (prescription, OTC,
e)bScreeningbforbSTI’sb(ifbapplicable) complementarybalternativebtherapies)
Pertinentbsexualbhistory:bNotbsexuallybactivebandb Antacidsbasbneededbforb"heartburn"
deniesbanybsexualbconcerns Ibuprofenb400bmgbthreebtimesbdailybasbneededbforbkneebpainb
Multivitamins
ReviewbofbSystems:b(ROS)bUsebthisbcolumnbtob FrombthebROS:blist/highlightbthebcurrentbsymptoms/complaintsbtobgeneratebab
documentbthebROSbbelow. listbofb“reportedborbdenied”bsymptomsbbelow:
General:bReportsbsomebweightbloss,bfever,bnightb
sweats,bandbdifficultybsleeping PertinentbpositivebROS:bReportsbsomebweightbloss,bfever,bnightbsweats,bandbdiff
HEENT:bDeniesbheadaches,bchangesbinbvision, icultybsleeping;bRUQbabdominalbthatbworsensbwithbfoodbandbpainbscalebofb2-
b3/10bandbprogressesbtob6-7/10,b6/10.bAnorexia,bnauseabandbvomitingbatbonset.
7 IHIMAN=Ihuman CASE-STUDY-EVITA-
b b
ALONSO ,48YRS OLD FEMALE HISPANIC
b b b b b
AMERICAN FEMALE CC= Abdominal-
b b b
pain 3 Different version
b b b b
]
,CC:b48by/obF HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
b b b b b b b
Chiefb complaintb isb ab shortb 1-
2b statementb orb wordb phrasebfrombpatientbandbshouldbbeblis Mrs.bAlonsobisbab48-year-
tedbinb“quotes” oldbfemalebpatientbwhobpresentedbtobthebclinicbwithbabprogressive,bintermittentbrigh
tbupperbquadrantbpainbforbthebpastb2bweeksbandbwhichbhasbincreasedbinbseveritybinbt
“Mybstomachbhasbbeenbhurtingbreallybbadboverbt hebpastb2bdays.bThebpainbradiatesbtobthebrightbshoulder.bShebalsobcomplainsbofbassoc
hebpastb2bseeks” iatedbsymptomsblikebnausea,bvomiting,banorexiabsincebthebpastb2bdays.bShebhasbhadb
previousbrecurrentbself-
resolvingbsymptomsboverbtheblastbonebyear.bPainbusedbtobbebprecipitatedbbybfastbfoo
dbbutbnotboccursbwithballbfoodsbandbunresponsivebwithbantacidsbandbNSAIDS.
Onset:b2bweeksbago,bwithbsymptomsbbecomingbmorebdreadfulb2bdaysbagobLocation
:bRightbupperbquadrantbandboccasionallybradiatedbtobthebrightbshoulderbDuration:bPa
inbhasbbeenbconstantbsincebitbstartedbthisbtime;binbthebpastbitbonlyblastedb1-2bdays.
Character:bCrampybgnawbachiness
Aggravating/alleviatingbfactors:bPainbgetsbworsebwithbmealsbandbunresolvedbwithb
antacidsbandbNSAIDs
Relatedbsymptoms:bNausea.bVomiting,banorexiabwithbonsetbofbsymptomsb2bdaysb
ago.bDeniesbanybrecentbexposurebtobotherbillbcontacts.bShebhasbhadbsimilarbsympto
msbpreviously
Treatments:bHasbtriedbOTCbantacidsbandbibuprofenbwithoutbreliefbSignificance:
bPainbstarts bwithbabscalebofb2-3bandbgetsbupbtob6-
7.bShebreportsbpainbhasbkeptbherbhomebfrombwork.
PMHxbchild/adultbillness/hospitalizations/immunizatio Surh type/when/why/complications
b
ns
Negativeb forb anyb chronicb illnesses.b Sheb hasbocca Tubalbligation
sionalbheartburnbandbarthritis
Frequentbepisodesbofbcommonbcoldsbandbasbchildb
Nobhospitalizations,btraumaborbotherbinjuries
, Immunizations:bStatesbherbimmunizationsbareb
current.bShebhadbthebinfluenzabvaccinebthisbse
asonbandbstillbgotbthebflu.
Fahm TX
Grandparentsb(ifbknown)/Parents/siblings/children Tobacco/vaping/ETOH/illicitbdrugbuse/occupational/environmental/relationships
Grandparents- Shebreportsbthatbshebdrinksbabglassbofbwinebwithbdinnerbmostbnights;bShebdeniesba
bstates bnobknownbhistorybFatherbisb70byears-
nybtobaccoborbrecreationalbdrugbuse
oldbandbstillbalivebandbwellb(70):bheartbdisease,
bpepticbulcerbdisease
Motherbisb69byears-
oldbandbalive:bbreastbcancerbinbremission;bcholecys
tectomybforbcholelithiasis
ReproductivebHex Allergiesb(Food,bDrug,bEnvironmental,betc.)
Female:bAgebofbmenarche/menstruationbcyclebduration/
gravidabparabstatus/Childbirthbhex/sexualbhexbandbconc Nobknownbdrugballergies
erns/LMP/menopause
Breast/cervicalbscreeningb(ifbany)
Male:bSexualbhexbandbconcerns/issuesbwithbfertilityb(
ifbany)/Testicularborbprostatebscreeningb(ifbapplicabl List of Medications/supplements (prescription, OTC,
e)bScreeningbforbSTI’sb(ifbapplicable) complementarybalternativebtherapies)
Pertinentbsexualbhistory:bNotbsexuallybactivebandb Antacidsbasbneededbforb"heartburn"
deniesbanybsexualbconcerns Ibuprofenb400bmgbthreebtimesbdailybasbneededbforbkneebpainb
Multivitamins
ReviewbofbSystems:b(ROS)bUsebthisbcolumnbtob FrombthebROS:blist/highlightbthebcurrentbsymptoms/complaintsbtobgeneratebab
documentbthebROSbbelow. listbofb“reportedborbdenied”bsymptomsbbelow:
General:bReportsbsomebweightbloss,bfever,bnightb
sweats,bandbdifficultybsleeping PertinentbpositivebROS:bReportsbsomebweightbloss,bfever,bnightbsweats,bandbdiff
HEENT:bDeniesbheadaches,bchangesbinbvision, icultybsleeping;bRUQbabdominalbthatbworsensbwithbfoodbandbpainbscalebofb2-
b3/10bandbprogressesbtob6-7/10,b6/10.bAnorexia,bnauseabandbvomitingbatbonset.
