NRNP-6531-WEEK-7 IHIMAN=Ihuman
CASE-STUDY-EVITA-ALONSO ,48YRS
OLD FEMALE HISPANIC AMERICAN
FEMALE CC= Abdominal-pain 3 Different
version
]
,CC:164816y/o16F HPI:16pertinent16s/s;16+/-16ROS/prior16episodes/recent16travel/ill16contacts
Chief1 6 complaint1 6 is1 6 a1 6 short1 6 1-
21 6 statement1 6 or1 6 word1 6 phrase16from16patient16and16s Mrs.16Alonso16is16a1648-year-
hould16be16listed16in16“quotes” old16female16patient16who16presented16to16the16clinic16with16a16progressive,16inte
rmittent16right16upper16quadrant16pain16for16the16past16216weeks16and16which16ha
“My16stomach16has16been16hurting16really16ba s16increased16in16severity16in16the16past16216days.16The16pain16radiates16to16the16r
d16over16the16past16216seeks” ight16shoulder.16She16also16complains16of16associated16symptoms16like16nausea,1
6vomiting,16anorexia16since16the16past16216days.16She16has16had16previous16recurr
ent16self-
resolving16symptoms16over16the16last16one16year.16Pain16used16to16be16precipitate
d16by16fast16food16but16not16occurs16with16all16foods16and16unresponsive16with16an
tacids16and16NSAIDS.
Onset:16216weeks16ago,16with16symptoms16becoming16more16dreadful16216days16a
go16Location:16Right16upper16quadrant16and16occasionally16radiated16to16the16righ
t16shoulder16Duration:16Pain16has16been16constant16since16it16started16this16time;16i
n16the16past16it16only16lasted161-216days.
Character:16Crampy16gnaw16achiness
Aggravating/alleviating16factors:16Pain16gets16worse16with16meals16and16unresolv
ed16with16antacids16and16NSAIDs
Related16symptoms:16Nausea.16Vomiting,16anorexia16with16onset16of16symptom
s16216days16ago.16Denies16any16recent16exposure16to16other16ill16contacts.16She16h
as16had16similar16symptoms16previously
Treatments:16Has16tried16OTC16antacids16and16ibuprofen16without16relief16Sig
nificance:16Pain16starts16with16a16scale16of162-316and16gets16up16to166-
7.16She16reports16pain16has16kept16her16home16from16work.
PMHx16child/adult16illness/hospitalizations/immuniza Surh16type/when/why/complications
tions
Negative1 6 for1 6 any1 6 chronic1 6 illnesses.1 6 She1 Tubal16ligation
6 has16occasional16heartburn16and16arthritis
Frequent16episodes16of16common16colds16and16a
s16child16No16hospitalizations,16trauma16or16other
16injuries
, Immunizations:16States16her16immunizations1
6are16current.16She16had16the16influenza16vacc
ine16this16season16and16still16got16the16flu.
Fahm TX
Grandparents16(if16known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit16drug16use/occupational/environmental/relationships
Grandparents- She16reports16that16she16drinks16a16glass16of16wine16with16dinner16most16night
16states16no16known16history16Father16is16701
s;16She16denies16any16tobacco16or16recreational16drug16use
6years-
old16and16still16alive16and16well16(70):16heart1
6disease,16peptic16ulcer16disease
Mother16is166916years-
old16and16alive:16breast16cancer16in16remission;16c
holecystectomy16for16cholelithiasis
Reproductive16Hex Allergies16(Food,16Drug,16Environmental,16etc.)
Female:16Age16of16menarche/menstruation16cycle16d
uration/gravida16para16status/Childbirth16hex/sexual1 No16known16drug16allergies
6hex16and16concerns/LMP/menopause
Breast/cervical16screening16(if16any)
Male:16Sexual16hex16and16concerns/issues16with16
fertility16(if16any)/Testicular16or16prostate16screen List of Medications/supplements (prescription, OTC,
ing16(if16applicable)16Screening16for16STI’s16(if16ap complementary16alternative16therapies)
plicable)
Antacids16as16needed16for16"heartburn"
Pertinent16sexual16history:16Not16sexually16activ Ibuprofen1640016mg16three16times16daily16as16needed16for16
e16and16denies16any16sexual16concerns knee16pain16Multivitamins
Review16of16Systems:16(ROS)16Use16this16colu From16the16ROS:16list/highlight16the16current16symptoms/complaints16to16ge
mn16to16document16the16ROS16below. nerate16a16list16of16“reported16or16denied”16symptoms16below:
General:16Reports16some16 weight16loss,16fever,
16night16sweats,16and16difficulty16sleeping
Pertinent16positive16ROS:16Reports16some16weight16loss,16fever,16night16swea
HEENT:16Denies16headaches,16changes16in16visi ts,16and16difficulty16sleeping;16RUQ16abdominal16that16worsens16with16food16a
on, nd16pain16scale16of162-163/1016and16progresses16to166-
7/10,166/10.16Anorexia,16nausea16and16vomiting16at16onset.
CASE-STUDY-EVITA-ALONSO ,48YRS
OLD FEMALE HISPANIC AMERICAN
FEMALE CC= Abdominal-pain 3 Different
version
]
,CC:164816y/o16F HPI:16pertinent16s/s;16+/-16ROS/prior16episodes/recent16travel/ill16contacts
Chief1 6 complaint1 6 is1 6 a1 6 short1 6 1-
21 6 statement1 6 or1 6 word1 6 phrase16from16patient16and16s Mrs.16Alonso16is16a1648-year-
hould16be16listed16in16“quotes” old16female16patient16who16presented16to16the16clinic16with16a16progressive,16inte
rmittent16right16upper16quadrant16pain16for16the16past16216weeks16and16which16ha
“My16stomach16has16been16hurting16really16ba s16increased16in16severity16in16the16past16216days.16The16pain16radiates16to16the16r
d16over16the16past16216seeks” ight16shoulder.16She16also16complains16of16associated16symptoms16like16nausea,1
6vomiting,16anorexia16since16the16past16216days.16She16has16had16previous16recurr
ent16self-
resolving16symptoms16over16the16last16one16year.16Pain16used16to16be16precipitate
d16by16fast16food16but16not16occurs16with16all16foods16and16unresponsive16with16an
tacids16and16NSAIDS.
Onset:16216weeks16ago,16with16symptoms16becoming16more16dreadful16216days16a
go16Location:16Right16upper16quadrant16and16occasionally16radiated16to16the16righ
t16shoulder16Duration:16Pain16has16been16constant16since16it16started16this16time;16i
n16the16past16it16only16lasted161-216days.
Character:16Crampy16gnaw16achiness
Aggravating/alleviating16factors:16Pain16gets16worse16with16meals16and16unresolv
ed16with16antacids16and16NSAIDs
Related16symptoms:16Nausea.16Vomiting,16anorexia16with16onset16of16symptom
s16216days16ago.16Denies16any16recent16exposure16to16other16ill16contacts.16She16h
as16had16similar16symptoms16previously
Treatments:16Has16tried16OTC16antacids16and16ibuprofen16without16relief16Sig
nificance:16Pain16starts16with16a16scale16of162-316and16gets16up16to166-
7.16She16reports16pain16has16kept16her16home16from16work.
PMHx16child/adult16illness/hospitalizations/immuniza Surh16type/when/why/complications
tions
Negative1 6 for1 6 any1 6 chronic1 6 illnesses.1 6 She1 Tubal16ligation
6 has16occasional16heartburn16and16arthritis
Frequent16episodes16of16common16colds16and16a
s16child16No16hospitalizations,16trauma16or16other
16injuries
, Immunizations:16States16her16immunizations1
6are16current.16She16had16the16influenza16vacc
ine16this16season16and16still16got16the16flu.
Fahm TX
Grandparents16(if16known)/Parents/siblings/children Tobacco/vaping/ETOH/illicit16drug16use/occupational/environmental/relationships
Grandparents- She16reports16that16she16drinks16a16glass16of16wine16with16dinner16most16night
16states16no16known16history16Father16is16701
s;16She16denies16any16tobacco16or16recreational16drug16use
6years-
old16and16still16alive16and16well16(70):16heart1
6disease,16peptic16ulcer16disease
Mother16is166916years-
old16and16alive:16breast16cancer16in16remission;16c
holecystectomy16for16cholelithiasis
Reproductive16Hex Allergies16(Food,16Drug,16Environmental,16etc.)
Female:16Age16of16menarche/menstruation16cycle16d
uration/gravida16para16status/Childbirth16hex/sexual1 No16known16drug16allergies
6hex16and16concerns/LMP/menopause
Breast/cervical16screening16(if16any)
Male:16Sexual16hex16and16concerns/issues16with16
fertility16(if16any)/Testicular16or16prostate16screen List of Medications/supplements (prescription, OTC,
ing16(if16applicable)16Screening16for16STI’s16(if16ap complementary16alternative16therapies)
plicable)
Antacids16as16needed16for16"heartburn"
Pertinent16sexual16history:16Not16sexually16activ Ibuprofen1640016mg16three16times16daily16as16needed16for16
e16and16denies16any16sexual16concerns knee16pain16Multivitamins
Review16of16Systems:16(ROS)16Use16this16colu From16the16ROS:16list/highlight16the16current16symptoms/complaints16to16ge
mn16to16document16the16ROS16below. nerate16a16list16of16“reported16or16denied”16symptoms16below:
General:16Reports16some16 weight16loss,16fever,
16night16sweats,16and16difficulty16sleeping
Pertinent16positive16ROS:16Reports16some16weight16loss,16fever,16night16swea
HEENT:16Denies16headaches,16changes16in16visi ts,16and16difficulty16sleeping;16RUQ16abdominal16that16worsens16with16food16a
on, nd16pain16scale16of162-163/1016and16progresses16to166-
7/10,166/10.16Anorexia,16nausea16and16vomiting16at16onset.
