IHUMAN CASE 4 Evita Alfonso Perptual Aseme

Perpetual Anita Aseme

IHUMAN CASE # 4: GI Evita Alfonso

NURS5342

Advanced Health Assessment

LaMicha Hogan, APRN, MSN FNP-BC

Molly Toon, DNP, APRN, CPNP-PC Date

March 21, 2021

Case: Evita Alfonso

Date: March 21, 2021

CC: 48 y/o F

Chief complaint is a short 1-2 statement or word phrase

from patient and should be listed in “quotes”

“My stomach has been hurting really bad over

the past 2 seeks”

HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts

Mrs. Alfonso is a 48-year-old female patient who presented to the clinic with a

progressive, intermittent right upper quadrant pain 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 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.

PMHx child/adult

illness/hospitalizations/immunizations

Negative for any chronic illnesses. She has

occasional heartburn and arthritis

Frequent episodes of common colds and as child

No hospitalizations, trauma or other injuries

SurgHx type/when/why/complications

Tubal ligation

Case: Evita Alfonso

Date: March 21, 2021

Immunizations: States her immunizations are

current. She had the influenza vaccine this

season and still got the flu.

FamHx

Grandparents (if known)/Parents/siblings/children

Grandparents- states no known history

Father is 70 years-old and still alive and well

(70): heart disease, peptic ulcer disease

Mother is 69 years-old and alive: breast cancer

in remission; cholecystectomy for cholelithiasis

SHx

Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships

She reports that she drinks a glass of wine with dinner most nights; She denies

any tobacco or recreational drug use

Reproductive Hx

Female:Age of menarche/menstruation cycle

duration/gravida para status/Childbirth hx/sexual hx and

concerns/LMP/menopause

Breast/cervical screening (if any)

Male: Sexual hx and concerns/issues with fertility (if

any)/Testicular or prostate screening (if applicable)

Screening for STI’s (if applicable)

Pertinent sexual history: Not sexually active and

denies any sexual concerns

Allergies (Food, Drug, Environmental, etc)

No known drug allergies

List of Medications/supplements (prescription, OTC, complementary

alternative therapies)

Antacids as needed for "heartburn"

Ibuprofen 400 mg three times daily as needed for knee pain

Multivitamins

Review of Systems: (ROS) Use this column to

document the ROS below.

General: Reports some weight loss, fever, night

sweats, and difficulty sleeping

HEENT: Denies headaches, changes in vision,

From the ROS: list/highlight the current symptoms/complaints to generate a

list of “reported or denied” symptoms below:

Pertinent positive ROS: Reports some weight loss, fever, night sweats, and

difficulty sleeping; RUQ abdominal that worsens with food and pain scale of 2-

3/10 and progresses to 6-7/10, 6/10. Anorexia, nausea and vomiting at onset